Unscripted - The AMCP Podcast: Understanding Psoriasis, Treatment Options and Patient Impact

Fred Goldstein  0:01 
Welcome to Unscripted. The AMCP podcast, a look inside managed care pharmacy. Listen in as experts explore the challenges, innovations and opportunities shaping healthcare for millions of patients. This episode of Unscripted, the AMCP podcast is sponsored by AbbVie Inc. AbbVie, we find answers that make life better for patients in our world. August is National Psoriasis Awareness Month. In this episode, we'll be discussing its impact on patients, treatment guidelines and its pharmacoeconomics with Dr Harrison Nguyen. Dr Nguyen is a double board certified dermatologist, most micrographic surgeon and clinical researcher in Houston, Texas. He serves as Managing Director at Harrison dermatology and research group clinical assistant professor of dermatology and health economics at the University of Houston College of Medicine, and clinical assistant professor of dermatology at the Baylor College of Medicine. Welcome, Dr Nguyen, Thanks, Fred, delighted to be with you today. Yeah, it's great to have you on why don't we start? Could you give us sort of a little background on psoriasis?

Harrison Nguyen  1:01  
yeah, absolutely. And what a timely discussion. August is Psoriasis Awareness Month. And so let's spend some time talking about psoriasis impact on our patients and how we can really treat this. And so I explained to patients that Psoriasis is a chronic, systemic inflammatory condition, and I do that in a very deliberate way, and I explain each of those terms because it's important for each of our patients to know why, why each of those terms characterize his or her disease. So it's chronic, meaning that we don't have a cure for it. Systemic, meaning that inflammation is beyond just the skin. It affects the gut, the vessels, the joints, and we'll talk a little bit about that as well. Inflammatory. Think that's pretty self explain explanatory condition. And so it's characterized by pink, itchy, scaly plaques. And that's the classic presentation, but it can also present in other ways. Sometimes it presents in having little pustules or and depending on the skin type, it can have different tones to it as well. So it's not always straightforward to recognize, but it is a very common condition affecting approximately two to 3% of the population, and again, what we see on the skin often just represents the tip of the iceberg when it comes to inflammation. So for me, I have to spend time understanding how our patients are impacted by their disease, but also spending time explaining the implications of their disease and why this is different from some of the other conditions that impact the skin, such as acne or rosacea, which can have impact on quality of life but may not have the inflammatory component within that psoriasis, does

Fred Goldstein  2:54  
You mentioned an issue with the skin. So I assume there's some impact as people live with this disease and go places or see things. Interestingly, I was talking with a colleague just earlier today, and they mentioned they had a teenager coming to the clinic and had been struggling so much with it at school, they actually were home schooled, and they had to come into clinic through a back door. So it sounds like it got some pretty severe impacts for some individuals around their life.

Harrison Nguyen  3:19  
Yeah, absolutely, and that's really the crux of what we do in dermatology is, is focusing on patients quality of life and making their lives better, right? And so. So with psoriasis, it can on a very fundamental level, it can be very itchy, and it can also be painful. Pain is a symptom that is often under recognized and under discussed, but it is can be very painful, and you can imagine that if you have psoriasis, especially in areas that are critical to function, such as the hands and the feet, walking around with psoriasis can lead to maceration and tenderness, and So pain and itch are are our symptoms that can drive their condition. Now, beyond that, it can also impact their their self esteem, and so our skin is how we present ourselves to the world. And the story that you mentioned, Fred about you know this patient being embarrassed and entering different through a different part of the school, this is what we hear all the time, that our patients are embarrassed by the appearance, because they think when the world may perceive them to be different, they may perceive it to be an infectious condition, or that the patient isn't cleaning themselves. And these are all misconceptions that you know, we often hear when we're first explaining the diagnosis to the patient and understanding their experience of the disease. And so, yeah, quality of life really is a tremendous factor that we consider for psoriasis and in dermatology. 

Fred Goldstein  4:57  
So you really have to look at this much more broadly when you're thinking of treatment. Going beyond maybe bringing in other professionals and things like that to help?

Harrison Nguyen  5:03  
Yeah, absolutely. You know, we have to. We use different quality metrics. So certainly we rate things on different metrics from a research standpoint, to be able to quantify the patient's disease experience. But we also spend time talking to the patient about how it's impacting their work, how it's impacting their function, their self esteem, their relationships. And so it goes beyond just a number, but taking the time to communicate with the patient, o understand the impact of the disease on their quality of life, and understand they're also within this disease, high impact areas that maybe affect the individuals more than others. 

Fred Goldstein  5:33  
Can you discuss that a bit?

Harrison Nguyen  5:40  
Absolutely, Fred, that's such an important concept. I really hope our listeners will walk away with today understanding better. So to set the foundation, if I can just start with a framework of a concept called body surface area. Body Surface Area is a very simple concept, and what it aims to capture is the percentage of the patient's skin that a disease is impacting. And when, you know, I when we teach medical students and residents, we give them a very, a pretty quick and dirty, easy way to measure body surface area, approximately the size of a patient's palm is equivalent to 1% body surface area. Now, historically, when we were in the early phases of understanding psoriasis, the way that it was classified was that patients with 3% or less body surface area, so three palms or less body surface area was considered mild psoriasis, three to 10% was considered moderate, and then greater than 10% body surface area was considered severe psoriasis, right? But what we have understood over time is that body surface area is a very limited way of capturing a patient's disease experience, right? And so you can imagine 1% body surface area on the face is very much different than 1% body surface area on the back or the arm, where it can be more easily hidden. And so these areas where we know that body surface area percentage doesn't tell the story, both in terms of quality of life and then also disease implications. I'll get to that momentarily. These have been areas that have been coined specialty site areas, or high impact site areas, similar term for the same concept. And so these high impact site areas, or the specialty site areas, include the scalp, the face, the groin, hands and feet, the nails and then inner Trojan is areas as well, again, so the scalp, the face, the groin, in nutritionist areas, so in the skin folds the hands and the feet and the nails. So these are all areas that are high impact site areas where you can imagine that if a patient had 1% body surface area on the scalp but was very itchy, flaky to the point where he or she was going around with flakes all around on his or her clothing. Is itching the scalp all the time where he or she can function at work, whereas people are thinking that that the patient has lice or something infectious, right, that 1% body surface area of scalp involvement is not equivalent in disease experience to 1% of typical truncal involvement, for example. And so that's why it's a really important concept for us to define, and to give you that that context about Fred.

Fred Goldstein  8:33  
So when individuals come in like that, you really take a little bit of a different approach, or

Harrison Nguyen  8:38  
absolutely and so these specialty site are high impact areas. We know a couple things about them. First, that they are even more they have even more impact on quality of life than other areas of involvement. Second, we know that topical treatments, when I say topical and talk about creams, ointments, lotions solutions, they're not as effective at treating these specialty site areas. You can imagine, for example, we go back to that patient on the scalp trying to put ointment, greasy ointment or cream through, especially if here he or she has hair, it can be very difficult to apply and to penetrate. Same goes with like the nails or the hands and the feet. These are areas where topical treatments can be very limited, and so it has to do with impact on quality of life. We know that topical treatments are not as effective. And then the third thing is that some of these specialty site areas represent harbingers or risk factors for developing psoriatic arthritis, and we'll talk about psoriatic arthritis, but the nail whenever you have nail involvement, you have three times risk of developing psoriatic arthritis, and when you have scalp involvement, you have four times greater risk of developing psoriatic arthritis. And so that's why it's very important that we identify patients beyond just body surface area. That we understand, are they having, are they having specialty site involvement? Because this can be harbingers for more grave manifestations of theirs, of their disease.

Fred Goldstein  10:11  
This episode is sponsored by AbbVie Inc. Our guest is Dr Harrison Nguyen. So let's talk a little bit about treatment guidelines. You've mentioned some of the issues and and the higher risk associated with various areas of this, of the skin being impacted. Tell us about the treatment guidelines and how you how you look at that. 

Harrison Nguyen  10:26  
That's really evolved through the years. It's even evolved when, since I started practicing medicine, this is psoriasis, has been an area where there's been tremendous innovation for our patients, where we now have really effective and and safe options for treating their psoriatic disease, and so historically, first line treatment has been with topical therapy. So different creams and ointments and solutions and the mainstay of them have been topical steroids. Right steroids to that patients can apply to these areas. Now, remember, there's some limitations, right already, limitations with applying creams and different topical treatments to adherence to efficacy. With chronic use, topical steroids can have systemic implications, so that patients can develop atrophy of their skin, so their skin can thin. And then, when they're applying to large body surface areas over time, or they're using ultra potent topical steroids, there can be systemic absorption of steroids, which, as we know, can has is are, are vast. You know, one of the things that we talk about all time is osteoporosis and cataracts, different types of things that steroids can affect when they are systemically absorbed. Now topical still represent a main first line treatment, but other first line treatments that to be aware of is that we now have two other non steroidal treatments for psoriasis. So we have Zarif as well as vitama, which are non steroidal topical agents, and then we also have, can, historically have been able to use light therapy. So ultraviolet light can be effective for reducing the inflammation of psoriasis. But one of the challenges of that is that patients have to come a couple times a week to undergo light treatment. And it's it can be very burdensome for patients who who are working or have busy home lives, and so remember creams, ointments, light treatments, they don't, they don't address the systemic and inflammatory nature of the disease, right? They just address this, the tip of the iceberg, what's on the skin. And so we then often had to escalate to systemic treatments. So systemic treatments, back in the days, we were using kind of blunt objects, if you if you will, to treat psoriasis, so things like methotrexate, azathioprine, mycophenolate. And so these treatments are now, from my perspective, completely archaic and not not at all relevant for treating psoriasis anymore. They didn't work so well and they could have toxic effects on the liver or on the blood counts. And so fortunately, we now have biologics and other systemic agents that that we can use to treat patients. And so we have more than 10 biologic agents. We have two FDA approved treatments to take by mouth, and they provide really good efficacy and safety for our patients that really address the systemic inflammatory nature. Now in terms of how we move up that ladder, you know, historically, we have started with first line and then we've gone to second line and then third line. But what we know is that when patients come in with severe disease, it doesn't make sense for us to write them a prescription for a topical steroid and send them home, right? Because that's not going to it's going to be too onerous, too burdensome, and it's good, it's not going to be effective for their disease. And so when you talk about first line, second line, etc, I want us to be very deliberate about talking because it should not be used as a tip, as a mandated step wise approach that clinicians have to go through to fail step one, step two, to get into step three, we really need the tools to be able to find the right treatments for the right patient at the right time. And

Fred Goldstein  14:24  
so does as you talk about that, and you typically see that as you say, Hey, we're going to start here. And you fail. There we go. The next one. You fail. There we go, next one. So does it make sense in many of these cases, then to just start reverse that, in a sense, and start at the top?

Harrison Nguyen  14:38  
Yeah. Well, I for for some patients, if I know that topical treatments are not going to be sufficient, let's say they have specialty site involvement, or they have too extensive disease, or they have maybe early joint involvement, running them a topical therapy is not going to be enough. It's not going it's going to waste the patient's time. It's going to waste system. Resources. So it does not make sense for us to have to go through a step wise approach. That's where I am a big advocate for making sure that we're able to provide patients with the right therapy at the right time. So not so it's not necessarily going backwards, because for some patients at a patient today, who you know, had 3% by surface area, not, not very much affected by her disease, and really preferred just to use topical treatments. And for that patient, topical treatments was the right option. She left with a topical steroid. And I think we're going to do a good job of being able to control her disease and we explain the systemic implications. And she knows that she needs to watch out for that, be mindful of that. But for her, I think that was the right option. But you contrast that with another patient that I also saw today, 3% body surface area, but affecting the nails, affecting the scalp, super itchy, also affecting the inner parts of the ears, where creams are going to be hard for her to apply, especially with topical steroids we don't want to be putting in in on the face and highly sensitive areas over time. That was not the right treatment, and that was a patient I immediately put on a biologic agent due to the high impact, high impact site areas and the burden disease for that patient.

Fred Goldstein  16:16  
So really, a good example of a collaborative approach between the doctor and the patient to determine what's the best course for each individual. That's right. Fred, that's right. That's what it's all about. And when you think about this from a pharmacoeconomic approach, obviously differences in cost, etc, differences in potential outcome. How do you weigh that? How does that look?

Harrison Nguyen  16:33  
Yeah. You know, as you may have mentioned in my intro, I'm a health economist by training, and I do a lot of health economics research, and I recognize the importance of being able to control costs in our system, but it's also important to have the lens of how impactful this disease is beyond just quality of life, it can impact the joints, where, when you develop psoriatic arthritis of the joints. The disease is debilitating and can be is often irreversible, and so patients can develop progressive, debilitating disease where they lose the ability to function right. It can, in fact, impact the the hearts and the vessels, right. So patients with psoriasis, especially moderate to severe psoriasis, it represents an independent risk factor for developing a cardiovascular event, so like a stroke or a heart attack. And so just in the same way, we treat patients with for have high blood pressure, cholesterol, high cholesterol, diabetes, this represents an independent risk factor for developing a cardiovascular event, right? And so it's important for us to recognize the implications of what happens if we don't, if we inadequately control this patient's disease, right? So it may seem like on the front end, if, if we are putting a patient on a biologic, it represents an expense to the system, right, certainly more expensive than topical steroids. However, when you look at it through the lens of first the impact on systemic inflammation, what can we reduce systemically that is able to save money on the back end from reducing the care from metabolic syndrome, reducing the care from a cardiovascular event, reducing the care from from debilitating joint damage, right? So that there is cost savings over time by getting the patient on the right treatment from the get go, and then there's also cost savings from the perspective of what happens whenever patient have patients have lost work days. They've lost productivity because they're so impacted by their disease, whether it's they're itchy to the point where they can't function, they can't focus at work, whether it's to the point where they're embarrassed about their disease, if it's impacting their face or impacting out visible areas where they don't want to go into work, we know that psoriasis represents a major factor for lost productivity in our system. And so from both those lenses, Fred of the perspective of making sure that we can improve outcomes down the line, from a systemic standpoint, as well as being able to increase productivity of our workforce, it's really important that we have access to the right treatments for the right patient at the right time.

Fred Goldstein  19:26  
Yeah, I think, as you pointed out, I mean, from a population health perspective, obviously you got to look longer term and say, Hey, this down the road. If we don't fix it now or treat it now, we're going to face these others. And then employers really have gotten into this idea of presenteeism and absenteeism and how that impacts their workforce. So having people who can show up at work, feel comfortable at work and get their work done is critical.

Harrison Nguyen  19:49  
That's so critical, right? And we know that employer is really the way commercial insurance is administered in the US employees, especially large employers, are essentially self insurers, right? They. They represent insurers for their workforce, and so I get that being cost conscious is important for them. However, it's important to also view it through the lens of systemic inflammation as well as lost productivity, and so making sure that the employee, employees and their doctors have access to treatments that can really holistically treat their psoriasis, that systemic inflammatory nature in a way that's effective and safe for the patient, ultimately, is the best intervention from both a cost saving standpoint as well as just a treatment outcome standpoint. 

Fred Goldstein  20:36  
Yeah, just an interesting side point. You know, the the large insurers were typically the ones who were self insured. But now we see groups as small as 50 offering self insurance through various means. They've got now, so it's really expanded out into the workforce.

Harrison Nguyen  20:49  
Yeah, absolutely, you know, I just want to make a side note here, Fred, we, we first got our got our first biologic for psoriasis in the early 2000s right? And since then, we have more than 10 biological, systemic agents that we can use. And it's really the innovation has been really impressive. In the early 2000s we were talking about 50 to 75% clearance of psoriasis and patting ourselves on the back and saying, that's a huge win. But now we're at the point where we can get patients to 90 and 100% clearance, where patients don't have any evidence of psoriasis on their body, and it makes a big difference, right? And so from the payer standpoint, they may look okay. What's the difference between 25 to 30% clearance? It's a huge difference. It's a huge difference is and isn't a difference between productivity and non productivity. You can imagine the patient who has psoriasis covering the face or on the scalp, 50% clearance doesn't really get us to where we need us to be. We need to be for the patient to return back to normal function. What we know is that 9090 200% clearance is really gold standard in psoriasis, and we really need to be making sure that we maintain access to the treatments that can get patients to complete clear,

Fred Goldstein  22:09  
fascinating. Well, thank you so much, Dr. Nguyen, for joining us.

Harrison Nguyen  22:13  
Absolutely My pleasure. Thank you for tuning in and thanks for taking the time to learn about psoriasis, tremendously impactful disease that we treat. It's an honor to do so

Fred Goldstein  22:24  
Absolutely and thank you for listening to this episode of Unscripted, the AMCP podcast. This episode was sponsored by AbbVie Inc. For more information about AbbVie, go to abbvie.com you.