What Systemic Treatment Options Do I Have for My Psoriasis?

Psound Bytes™ Transcript: Episode 193

Release date: April 25, 2023

“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”

Shiva: My name is Shiva Mozaffarian and I’m here today to discuss systemic treatment choices with dermatologist Dr. Ahmad Shatil Amin who is the Medical Practice Director at the Northwestern Medicine Dermatology Department in Chicago where he’s also the Director of the Psoriasis Program and Co-Director of the Multidisciplinary Psoriatic Arthritis Clinic. A large focus of Dr. Amin’s clinical practice is on the management of psoriasis especially in the use of immunosuppressive and biologic medications. He is also a principal investigator for multiple psoriasis clinical trials exploring various treatment options. Before we begin our discussion with Dr. Amin, please take five minutes to participate in our survey which closes this Friday, April 28. If you’ve already participated – thank you! And if not, tell us what you think of Psound Bytes™ and how we can make our podcast better. We want to hear from you! Take the survey at psoriasis.org/podcastsurvey.

Welcome, Dr. Amin and thank you so much for taking the time to join us today. It's such a pleasure having you here to address systemic treatments. But first, let's start with a basic question. What are the four general types of treatment options prescribed to treat psoriasis or psoriatic arthritis?

Dr. Amin: Thank you for that question. It's a great place to start. So there are a lot of great treatment options for psoriasis and some of it kind of depends on how much psoriasis you have and what locations you have, where your psoriasis is. One of the first approaches of treatment is topical treatments. So these are your creams and ointments. They come in different categories. Some are topical steroids, and some are compounds of other sort of ingredients that can help with psoriasis. This can be helpful to people who have mild limited psoriasis. There's phototherapy. Phototherapy is using the ultraviolet light to help treat psoriasis. This is often done in the office, and this can be a good treatment choice for patients who have mild, moderate, or even sometimes severe psoriasis and a good option for patients who want to avoid any sort of medicinal therapy. Oral treatment options, some of these are older school medicines that are considered to be nonspecific immunomodulating medications. We have newer oral treatment options that are not as immunosuppressive and can be good options. And then we also have the injectable biologic options. So, these are large protein molecules that block certain signaling molecules in the immune system that drives psoriasis and these injectable biologic options are sometimes some of our most efficacious treatment options for patients who have moderate or severe psoriasis.

Shiva: So you just touched on the two types of systemic treatments. But can you please elaborate on how they work and how are they usually taken?

Dr. Amin: Yeah. So when we're talking about systemic treatments, we're talking about a treatment that works inside the body to control the overactive immune system signaling pathways that drives psoriasis. So, in order to get it to work inside the body, it has to be either taken as a pill, as an oral option or it has to be injected under the skin. And then it's distributed throughout the body, through our bloodstreams. So the two main systemic treatment options are either taking a pill, we have pills that modulate the immune system and enzymes that drives psoriasis or we have injectable medicines and those are the biologic medicines. These are injected because they're large proteins and they're injected under the skin, and they're distributed throughout their body, and they help again control the psoriasis from within our body instead of limited topical targeted treatments. There's also now some things called biosimilars and these are essentially biologic medicines or injectable medicines that are similar to some of the branded injectable medicines that are currently available in the market. But these are kind of like and you can think of them as like generic biologics. We don't use the term generic because they're not exactly the same exact protein structure but similar enough where they have very similar effects to their branded counterparts. Systemic therapy is really treating the underlying condition. It's a medicine that works inside the body. It's gonna treat some of the pathways that are overactive in our immune system that drive the psoriasis. So, it's really getting closer to treating the underlying condition of the psoriasis from within the body.

Shiva: And given the descriptions you just provided, when are systemic treatments indicated as a medication choice?

Dr. Amin: So, you can think about it, you know systemic treatments are indicated as an option for patients when they have psoriasis that's not getting better with some of the first treatments that we start with like the topical treatments. So if the topical treatments aren't working enough or they're too burdensome to use, that's a patient who qualifies for systemic treatment. That's a patient who would benefit from treating the psoriasis from within the body and controlling those overactive immune pathways inside the body that are driving the psoriasis. Sometimes we take into consideration how much psoriasis someone has on their body, their body surface area involvement. Sometimes it’s about where the psoriasis is. Psoriasis in some areas like the scalp and the hands and feet are very problematic, very, very bothersome, very uncomfortable and also very difficult to getting under control with just the creams and ointments. Sometimes it's also about how much the psoriasis is bothering someone. So someone who has just a little bit of psoriasis can sometimes still be very, very bothered by the psoriasis, depending on how it's affecting their quality of life, how it makes them feel, how uncomfortable they are with it. So it depends on that too as well, and sometimes other things that go along with psoriasis. So as we might talk about later, psoriatic arthritis is something that affects some people with psoriasis, and when someone has psoriatic arthritis if their symptoms are moderate or severe that's gonna affect our treatment choices as well.

Shiva: So, I wanted to talk more about oral systemic or non-biologic treatments. As you mentioned, we have medications that treat the body as a whole and new medications that are more targeted. Can you please talk about the medications that have been available for several years and how or when they are used? How effective are they in treating psoriatic disease?

Dr. Amin: Some of our older oral medicines that we've used for psoriasis, a couple of examples are cyclosporine and methotrexate. These are older medicines that have been around for a long time, and they are medicines that can work in treating sort of the underlying condition and treating psoriasis, and often patients do get good results. They're a little bit more broader immune sort of modulating medicines and not quite as targeted as some of our newer oral medicines or some of our biologic medicines. And because they're not as targeted, sometimes they have other side effects that come along with them, and they often do require a little bit of monitoring to make sure other body organs are responding to the medicine well and are not having any adverse events. They can work well in many situations. We still have a lot of patients in our clinic for example who are on drugs like methotrexate or acitretin. That's another example that I didn't mention earlier. But I think in 2023, we have fewer patients on these older systemic oral medications.

Shiva: And are there any cautions or risks associated with use of the traditional oral medications? For example, is damage to the liver or other adverse effects an issue with use of methotrexate?

Dr. Amin: It's something that we carefully monitor. Most of our patients they do really well, and we don't see any sort of liver injury or inflammation happening at high rates. It's not something that we commonly see, but it is something that has been rarely reported with the medication and so we do carefully check patients and their blood work to make sure that their liver is doing well, that there's no signs of injury or inflammation when someone is on methotrexate. So these drugs do require routine blood work monitoring and we're often checking someone's blood work every three to four months when they're on a medication like methotrexate. So most people tolerate it well. But potential liver inflammation is something that we monitor for. We're a little bit more hesitant to put someone on methotrexate who may have had a history of liver disease or have liver problems.

Shiva: So apremilast is an example of a more targeted oral treatment. How does apremilast work and when is it considered as a treatment option? How effective is it and are there any risks or side effects associated with its use?

Dr. Amin: Sure. That's a great question. Apremilast is a oral medicine. It's actually a small molecule and it blocks this enzyme called phosphodiesterase 4. Phosphodiesterase 4 actually is a small enzyme that is inside the cell, and when you block phosphodiesterase 4, it actually puts the cell in a more anti-inflammatory state. And it actually as a result drives down some of the pathways, some of the immune pathways that drives psoriasis. So it's a good treatment option for someone not doing well on their topical creams and ointments and who wants to do something more. But the patient may not be ready to necessarily go to an injectable biologic. For that patient apremilast may be a good option. It doesn't work for everyone. I think the effectiveness rate of apremilast is definitely a little bit lower than some of our biologic medicines. But for some patients it works just fine. It's generally a very safe medicine. It doesn't require any blood work monitoring. And there are really no common serious risks associated with this medicine. Some patients who do try apremilast will have a little bit of nausea, vomiting, diarrhea. That's the most common side effect. It happens in about 10 to 15% of people and other people tolerate it fine. But otherwise, we consider it a pretty safe medicine and can be an option for almost anyone who wants to do something more than topical treatments.

Shiva: So, Dr. Amin here on Psound Bytes™ we’ve been hearing a lot about JAK inhibitors lately. In episode 182 we spoke about JAK and TYK2 inhibitors which are also targeted oral treatments. In September 2022 a TYK2 inhibitor was approved for use in psoriasis – deucravacitinib, which many dermatologists have expressed excitement about. Can you please address how deucravacitinib works, how effective it is, and if there are any risks or side effects we should be aware about?

Dr. Amin: Yeah, absolutely. So like apremilast, deucravacitinib is also an oral medication and it's a small molecule that inhibits a different enzyme in the cell called TYK2. And it turns out when you inhibit TYK2, you also significantly inhibit some of the immune pathways that drive psoriasis. Everyone was really excited about deucravacitinib because prior to deucravacitinib, we only had one other targeted oral option. That was apremilast. So we really wanted something else. You know we wanted to have greater options in our toolbox, especially when patients decided and wanted to have an oral treatment. So we were really excited, and we were all also really excited when we saw the clinical trial data for deucravacitinib because the clinical trial data showed that deucravacitinib is actually a pretty darn effective oral treatment and the study was actually a head-to-head study comparing deucravacitinib to apremilast which actually showed that it's better, it's superior to apremilast. You can get more patients to 75 or 90% clearance compared to their baseline. So we were really excited when this oral option became available. Most patients tolerate deucravacitinib very well. It also is a medicine that doesn't have any common serious adverse events. We do need to check for TB prior to starting the medication and in some situations it's advised that we consider monitoring someone's cholesterol levels while they're on deucravacitinib because for some patients, their cholesterol levels can increase. One of the most important differences between deucravacitinib and apremilast is we don't see the nausea, vomiting, and diarrhea that sometimes we see in apremilast patients. We're not seeing that with patients on deucravacitinib.

Shiva: That's certainly good to know. Thank you. So, are there other JAK inhibitors used to treat psoriatic disease then?

Dr. Amin: Yeah, so you know, there are no other JAK inhibitors approved to treat the skin psoriasis, but the JAK inhibitors had been used to treat psoriatic arthritis. So for example upadacitinib is approved to treat psoriatic arthritis and you know it may help with the skin disease too as well. The company didn't go for FDA approval for the skin disease part of it, but we do know that some of these other JAK inhibitors can be helpful in patients who have the psoriatic arthritis.

Shiva: And I've heard there are more JAK inhibitors currently in clinical trials as well, so this is definitely an exciting target area.

Dr. Amin: That's right.

Shiva: So Dr. Amin, biologics are another type of systemic treatment. What types of biologics are used currently and how do they differ in action?

Dr. Amin: So a biologic medicine is basically a large protein that usually inhibits one of the human molecules that drives psoriasis. So there are a lot of different signaling molecules that drives psoriasis. In the biologic medicines that we have available, one of three signaling molecules. We have a few biologic medicines that block a signaling molecule called TNF alpha. TNF alpha is sort of this kind of master signaling molecule that affects a few different conditions and immune processes. And so we have some medicines that block TNF alpha inhibitors, and these are actually some of our older biologics that were first approved for treating psoriasis. We also have some biologics that block a different signaling molecule called interleukin-23. We have a few in that category. We have some biologics that block another signaling molecule of the immune system called interleukin-17. We have some biologics that block both interleukin-12 and 23. And a newer option that we have for certain patients who have a type of psoriasis called pustular psoriasis is a medicine that blocks a different signaling molecule called interleukin-36. So different biologics that inhibit basically different signaling molecules in the immune system that are known to drive psoriasis.

Shiva: So you mentioned IL-36 which is Spesolimab as a treatment for pustular psoriasis. How significant is this development as a treatment option for psoriasis?

Dr. Amin: Well, it's a big deal. Pustular psoriasis, we always thought was very different in a very fundamental way than regular plaque psoriasis. And we always had a lot of challenges in treating patients with pustular psoriasis with our currently available therapies, which were mostly studied for patients with plaque psoriasis. And so this new medicineSpesolimab is a medicine that inhibits this other signaling molecule called interleukin-36. And it turns out that interleukin-36 is really one of the key drivers for pustular psoriasis and as such this medicine has shown to have really great efficacy in treating this form of psoriasis. And in my experience probably does a much better job at treating this form of psoriasis than some of the other medicines that block some of the other signaling molecules.

Shiva: It's so good to hear we finally have a treatment specifically for pustular psoriasis which we all know is so difficult to treat and really impacts quality of life. So thank you so much for sharing that with us. In general, how effective are biologics and are there any risks or side effects associated with the use of biologics?

Dr. Amin: Generally speaking biologics are miraculous drugs. They're extremely effective in most scenarios. We are usually able to get our patients 75 or 90 or even in many cases 100% clear with biologic therapies. They really have been a big, big advancement in our field of psoriasis. And thankfully, most of our biologic medicines are very well tolerated. They carry very few common risks. The rate of serious risks or serious adverse events are generally very, very low. And obviously these medicines, they work with the immune system. So we always are carefully monitoring for infections. But we generally don't see serious infections happening at a common rate. But those are some of the things that we look out for. Some of the older biologic medicines like the medicines that block the TNF alpha signaling molecule, they have been associated with active tuberculosis infections. And that's why we check for TB before we start any patient on any of these biologic medications. You should have a careful discussion of risks and side effects with your doctor. But generally speaking, most patients do very well with these medicines.

Shiva: And is it possible to use systemic treatments in combination with other treatment options for psoriasis, say, topicals? And when would use of combination therapy be considered?

Dr. Amin: Most of our patients who are on systemic treatments also have prescriptions for topical therapies. Because even if you're on a systemic treatment, whether that's an oral treatment or a biologic treatment, there's a good chance that you'll still have a little bit of psoriasis here or there. And so patients will need to have a topical cream at home in case they wanna treat some of the areas that are still there. And so you can certainly still use a topical steroid cream or another type of topical cream for your psoriasis in combination with your systemic treatment and many of our patients have both at home.

Shiva: So Dr. Amin, are there any issues that can occur when you need to stop one biologic and switch to another?

Dr. Amin: Yeah, that’s a great question. Switching biologics is pretty seamless. There really aren't any major issues that happen. So once if you're on a biologic, reasons for switching may be because the biologic that you're currently on may not be as effective as it once was, or perhaps your insurance is asking you to switch and that happens sometimes too. Really switching biologics is really as easy as starting the new biologic as soon as you get it. We really don't have our patients wait for a prolonged period of time from their last injection of their old biologic to their new injection of their new biologic. As soon as they get their new biologic that we are trying to switch to, they start. So it's as easy as that.

Shiva: So, you mentioned biosimilars earlier and we've certainly heard a lot about biosimilars these past few years. A biosimilar was recently approved for use in psoriasis with more on the way. I've heard there are like seven being released this year. So I wanted to see what’s your opinion about the use of biosimilars in this area?

Dr. Amin: Biosimilars may be a good option for patients. They're generally designed to be as identical as they can be to their branded counterparts and should have similar levels of effectiveness, and also equal safety. I think it's possible that having biosimilars may reduce the cost of biologics. But I think one of the biggest challenges is going to be to see if some of the biosimilars have some of the same patient assistance programs (like copay cards and foundational assistance programs) for patients who can't afford the cost of the copays if they have the same sort of assistance that some of our branded medicines do. I think that's to be determined. But I think in general having biosimilars is a good advance and has the potential to kind of reduce the cost of biologic therapies.

Shiva: Yeah, good point. And are there any other exciting developments for systemic treatments in the future?

Dr. Amin: Sure. We have a lot of really good systemic options and there are other drugs in the pipeline. There are other small molecules in the pipeline that are being developed as oral therapies. We have at least one other biologic medicine which will be an interleukin-17 signaling molecule blocker which hopefully will be approved on the market sometime in the next several months as well. So the pipeline for psoriasis treatments is great. We already have a lot of really great options and I think will continue to have more options that will come down the road and I really honestly feel that our patients with psoriasis are very fortunate in the fact that we have really great options currently on the market and will continue to have good options and new options down the road as well.

Shiva: Yeah, definitely exciting times ahead. So, Dr. Amin I just wanted to say thank you for being here today. This has been such an informative discussion. We've spoken quite a lot about systemic treatments, but I wanted to know do you have any final comments you'd like to share with our listeners?

Dr. Amin: I would just say that going on a systemic treatment, whether that's an oral treatment or a biologic treatment is always an important discussion to have with your dermatologist to carefully talk about the benefits of the therapy and also the risks. And so, I just encourage everyone to be as informed as they can be and have an open discussion with your dermatology provider about the risks and benefits of these systemic therapies.

Shiva: Thank you Dr. Amin for such an invaluable discussion about systemic treatments and for promoting being informed about what treatment options are available. It’s such an important point for our listeners to take home. For our listeners, if you find yourself in need of more information about systemic treatment options contact our Patient Navigation Center by emailing education@psoriasis.org or by calling (800) 723-9166, option 1 to receive your copy of the “Systemic Treatments: Biologics and Oral Treatments Booklet” today. And a reminder, please take our survey which closes this Friday, and tell us what you think about Psound Bytes topics, the episodes, and speakers all at psoriasis.org/podcastsurvey. We look forward to receiving your feedback. And finally thank you to our sponsors who provided support on behalf of this Psound Bytes™ episode through unrestricted educational grants from Bristol Myers Squibb, Janssen, and UCB.

We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Google Play, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.  

This transcript has been created by a computer and edited by an NPF Volunteer.