Addressing Patient Concerns on Biologics for Psoriasis

What does your patient need to know at the first visit? Why is this information important?

At the first visit I discuss potential side effects. The ones that patients want to hear about are infection and cancer. Clinical studies do not seem to indicate an increased risk for infection. But is that what I tell the patient? No. I tell the patient that there may be a slightly increased risk for infection with biologics. I tell patients the prescribing information lists some rare and serious infections such as tuberculosis, hepatitis B reactivation, sepsis, invasive fungal infections, and opportunistic infections. I do say that if the patient is young and healthy, the risk is relatively low. I do tell the patient that we do check the things that we can check, such as screening for tuberculosis and hepatitis B virus.

Once a patient starts a biologic, I ask him/her to tell me or the primary care physician if he/she develops fevers, chills, weight loss, chronic cough, or an illness that lasts 1 week or more. I emphasize that high-risk patients—those who are elderly, have chronic kidney or liver disease, or have uncontrolled diabetes—should be more vigilant for signs of infection than otherwise-healthy patients.

The word cancer is scary for patients, so I mention that patients with psoriasis are more likely to develop lymphoma, which may be related to having psoriasis itself, not to therapies used to treat psoriasis. For tumor necrosis factor inhibitors, there is a warning about an increased risk for nonmelanoma skin cancers, which has been confirmed in some studies, so I tell patients that it is important to come in at least every 6 months to evaluate their psoriasis but also to check for skin cancers.

I also review with patients that many times their insurance company will require them to fail a traditional systemic therapy first before they can start a biologic. Also, monthly co-pays for a biologic likely will be higher than oral therapies they have used.

How do you keep patients compliant with treatment?

Patients usually want to be compliant on their own, as they will see how effective the biologic is and how clear their skin will become while on therapy. They will see that if they take a break for whatever reason (eg, ran out of medicine, went on vacation, loss of medical insurance), the psoriasis will return, perhaps with a vengeance.

I remind patients who are not compliant with biologic therapy that the body may produce antibodies against the biologic itself if there is a substantial break from therapy, which may make the biologic less effective over time.

If the patient wants to reduce the dose but not stop it completely, I recommend to increase the interval of the maintenance dosing by 1 day after each injection and see if the psoriasis slowly returns. If it does return, then he/she should reduce the interval of the maintenance dosing by 1 day and hold that interval.

What do you do if they refuse treatment?

I stress to patients that biologics are typically the best long-term treatment with the highest levels of effectiveness and safety for psoriasis. In the rare case of a patient refusing a biologic, I discuss other options such as oral therapy (eg, methotrexate, cyclosporine, acitretin, apremilast) or phototherapy. If the patient is a candidate for biologic therapy, topical therapy may not be adequate to treat a large body surface area affected.

What resources do you recommend to patients for more information?

The National Psoriasis Foundation has recently published an updated patient booklet, “Systemic Medications for Psoriasis and Psoriatic Arthritis,” that I would encourage all patients to read for further information.

Suggested Reading

National Psoriasis Foundation. Systemic medications for psoriasis and psoriatic arthritis. https://www.psoriasis.org/sites/default/files/systemics_booklet.pdf. Accessed January 11, 2016.