Choosing a Biologic in Psoriasis With Ahmad Amin, MD, FAAD

Ahmad Amin, MD, FAAD, of Northwest Medicine, spoke at a session called, "Biological Bootcamp: How to Select the Best Biologics for Your Psoriasis Patient," at the 2023 Society of Dermatology Physician Assistants (SDPA) Annual Summer Dermatology Conference in Boston, Massachusetts.

Amin told Dermatology Times® what he hopes attendees will take away from his talk, as well as offering top considerations and best practices for biologic treatment selection.

Dermatology Times: What are key takeaways from your session, "Biological Bootcamp: How to Select the Best Biologics for Your Psoriasis Patient?"

Ahmad Amin, MD, FAAD: I think my biggest points were that: 'Hey, look, we're really lucky.' As providers, we can treat patients with psoriasis with such effective drugs with such amazing efficacy and such great safety. We're really lucky, and we have so many options to choose from.

And I made the point that all these options are good. I don't see really a bad medication out there in the options that we have. Now, some medicines, I think, have a slightly better batting average than others. But I don't think there's bad options out there. I think providers can choose which medicines kind of make the most sense for their practice, and some may decide, 'Hey, they want a little experience with all of them as they treat their patients with with psoriasis.'

And it is true that some of our newer medicine, when you look at IL-23 blockers, and then IL-17 blockers, are where a lot of us are sort of staying in these days, because these medicines tend to be less frequently dosed, and also have really high levels of skin clearance, as well.

I made the point that sometimes patients who have both skin and joint disease, it's a little bit of a dance trying to find which drug is going to work best for both their skin and their joints. And sometimes, it's hard to treat both at 100%, because you may have a drug that works really, really well for their joints, but doesn't work quite as well for their skin. And sometimes patients have to decide, which of those 2 domains bother them the most. We have some patients where it's the joints that really bothered them the most, so then we're choosing the drug that we think is going to be the best for their joints, but work okay for their skin, too, but maybe not necessarily the best one for their skin. So sometimes it does require a little bit of balance and discussion with your rheumatologist.

I also stressed that it's really important that whichever drugs that you use, that you really carefully study the package insert for these drugs, and you really carefully know the indications, how they're used, and also all the safety language that's in the package insert. With a lot of our newer drugs, a great thing is the safety information is limited, and there's not a whole lot to read about, but I do think you need to be very, very familiar with the package insert for all of these drugs.

I also made the point that there are many patients that we've had in our clinic where we we think they have psoriasis. But after failing 3, 4, or 5 different biologics, we realize that maybe it's not psoriasis. So I would say if you have a patient who has not done well with multiple psoriasis trials, never responded—again, these drugs generally are very, very good—that you should stop and maybe rethink if you might have a different diagnosis, or if the patient needs a different sort of therapy than one that's targeted towards psoriasis.

Dermatology Times: What are the top considerations when selecting a therapy for patients with psoriasis?

Amin: These are all really, really good drugs. They all work fairly well. I think some of the newer drugs probably are a little better at clearing, varying patients to higher levels of skin clearance. But we can sometimes get really good results, even with the older drugs, too, as well. And I think some of the considerations are, there are some patients who are hesitant to go on a biologic, hasn't to go on an injection, and they really need the medicine with the least frequent injection, so sometimes that's a consideration, and so we lean towards drugs that have the fewest number of injections.

Sometimes, patients have coexisting psoriatic arthritis. And while a lot of these drugs are approved to treat psoriatic arthritis, sometimes we may go with one drug over another if someone has really severe psoriatic arthritis, and if that's the primary complaint that they have. I think these are some of the some of the some of the considerations that we that we take into account when we're thinking about which biologic to choose.

And then there's also speed of onset. We know that there's the interleukin 17 class, [which] has, I think in my experience, speed of onset that probably surpasses some of the other biologic drugs and also some of the other oral drugs. And so [if] someone needs to get better really, really fast, sometimes that's where we're going, and that's where we're leaning towards. And then you have some patients that just don't want to start with injections, and for those patients, some of the small oral molecules may be a good place to start.

Dermatology Times: What are your recommended best practices for monitoring patients after beginning a new biologic/systemic treatment?

Amin: I think it depends on the drug, but again, I think again for all drugs, for all these biologic drugs, you definitely do need to check a TB test prior to starting—that's part of the label. And then for the anti-TNF drugs, you definitely need to check the Hepatitis B and C status.

Again, I think for monitoring, it's reasonable to check a TB test once a year. I don't think it's always required, but I think it's reasonable to do that, and I think it's reasonable if your patient doesn't have a primary care doc. I think it's reasonable to check a complete blood count and complete chemistry panel once a year; again, is it necessary for every patient? Maybe not. But I think it's reasonable to do that.

Apremilast is the one drug that we really don't do much lab monitoring at all. I don't typically check bloodwork prior to starting someone on apremilast, and I don't do any routine monitoring thereafter. I think the other oral small molecule drug also requires little monitoring outside that TB test that needs to be done at baseline for the package insert. But I think outside of that, there's limited monitoring that's needed.

[Transcript edited for clarity]