2020 Symposia Series 1 Managing the Spectrum of Psoriatic Disease - PowerPoint PPT Presentation

2020 Symposia Series 1

Managing the Spectrum of Psoriatic Disease in Primary Care

Learning Objectives • Implement screening for CV disease, metabolic syndrome, and psoriatic arthritis (PsA) in patients with psoriasis • Identify side effects of drug classes used in the treatment of psoriatic disease • Apply long-term management strategies for patients with psoriasis in coordination with a specialist CV = cardiovascular. 3

Clinical Burden of Psoriatic Disease in the United States • Chronic, multisystem inflammatory disorder • Affects >8 million individuals – 10% to 30% develop PsA • Symptoms usually develop by 15 to 25 years of age but can occur at any time • ~25% of patients have moderate to severe disease – Extensive involvement on hands, feet, scalp, or genitals • Negatively affects QoL, productivity, daily function • Risk factors include smoking, obesity, stress, genetics QoL = quality of life. Mayo Clinic. www.mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840?p=1. Accessed April 21, 2020; Menter A, et al. 4 J Am Acad Dermatol . 2019;80:1029-1072; National Psoriasis Foundation. www.psoriasis.org/content/statistics. Accessed April 21, 2020.

Plaque Psoriasis: Disease Characteristics • 80% to 90% of patients with psoriasis have Differential Diagnosis plaque psoriasis • Eczema ‒ Irregularly shaped, dry, thin plaques with • Combined silvery-white scaling eczema/psoriasis • ‒ Mycosis fungoides Tend to appear symmetrically • Plaque-stage cutaneous ‒ Often found on scalp, trunk, buttocks, T-cell lymphoma or limbs • Tinea corporis • Epidermal hyperproliferation • Bowen disease ‒ Clinically evident as raised, inflamed, • Subacute cutaneous lupus scaly red skin lesions; cracking, itching erythematosus ‒ Typically affects elbows, knees, scalp, but can appear anywhere Crow JM. Nature. 2012;492:S50-S51; Menter A, et al. J Am Acad Dermatol. 2008;58:826-850. 5

Plaque Psoriasis: Clinical Photos 6 Photos courtesy of Kristina Callis Duffin, MD.

Plaque Psoriasis: Clinical Photos (cont’d) 7 Photos courtesy of Veronica Richardson, MSN, ANP-BC, DCNP.

Guttate Psoriasis • Primarily affects young adults and children • Usually triggered by a bacterial infection such as strep throat • Small, waterdrop-shaped, scaling lesions on trunk, arms, legs, and scalp • Lesions covered by a fine scale (not as thick as typical plaques) • Often misdiagnosed as a reaction to penicillin drugs just given for strep infection • Often resolves after strep infection resolves • May portend future development of plaque psoriasis Photo used with permission from Visual Dx (2005). 8 Mayo Clinic. www.mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840?p=1. Accessed April 21, 2020.

Psoriatic Disease: Immunopathogenesis 1 2 3 Early disease Chronic disease Triggers T cells Neutrophils Mature dermal a β /  DCs KCs CD4/CD8 IL-23 IL-17A Chemokines TNF LL37 (keratinocyte-derived) IL-17F ADAMTSL5 (melanocyte-derived) T17 AMPs IL-12 IL-21 +DNA/RNA +RNA TNF IFN-  TLR7/8 TLR7/9 IFN-  Th1, Tc1 IFN-  / β TNF Inflammatory Psoriasis myeloid DCs IL-22 Amplification Myeloid DCs TNF Th22, Tc22 feedback IL-12 IL-23 4 Psoriasis AMP = antimicrobial peptide; DC = dendritic cell; IFN = interferon; KC = keratinocyte. 9 Arakawa A, et al. J Exp Med . 2015;212:2203-2212; Lande R, et al. Nat Commun . 2014;5:5621; Lowes MA, et al. Annu Rev Immunol . 2014;32:227-255.

Physical and Mental Rankings of Psoriasis and Other Diseases Best Functioning (1) to Worst Functioning (11) Heart failure 11 5 Psoriasis 10 9 Type 2 diabetes mellitus 9 3 Chronic lung disease 8 10 Myocardial infarction 7 4 Arthritis 6 7 Hypertension 5 2 Depression 4 11 Cancer 3 6 Dermatitis 2 8 Healthy 1 1 0 5 10 15 20 Physical rank Mental rank 10 Van Voorhees AS, et al. www.psoriasis.org/sites/default/files/npf_pocketguide_2018_0010.pdf. Accessed April 28, 2020.

NPF Treatment Target for Psoriasis Is ≤1% of BSA During Maintenance Preferred assessment BSA instrument in clinical practice Therapeutic Benefit Initiation Maintenance Phase Phase Either BSA ≤3% or BSA improvement Acceptable response after ≥75% from baseline at 3 months after treatment initiation treatment initiation BSA ≤1% at 3 months after treatment Target response after treatment initiation initiation BSA ≤1% at every 6 -month assessment Target response during Time maintenance therapy interval during maintenance therapy 11 Armstrong AW, et al. J Am Acad Dermatol. 2017;76:290-298.

Case Study: Lori, a 31-Year-Old Music Teacher With Scalp Psoriasis • 6-year history of psoriasis, primarily on the scalp, for which she has been applying an OTC anti-dandruff shampoo • Family history of multiple sclerosis • Mild depression treated with SSRI • Currently taking an oral contraceptive • New concerns ‒ Worsening itching and flaking of scalp behind her ears • Strategically covers these areas with her hairstyle • Visits a friend for haircuts; too embarrassed to go to salon 12 SSRI = selective serotonin reuptake inhibitor.

Calculating Extent of Psoriasis • May also be considered severe if it: – Involves the hands, feet, scalp, face, or genitals – Causes intractable pruritus – Has significant impact on QoL • Such an impact may justify use of systemic therapy Menter A, et al. J Am Acad Dermatol . 2019;80:1029-1072; Van Voorhees AS, et al. www.psoriasis.org/sites/default/files/npf_pocketguide_2018_0010.pdf. 13 Accessed May 23, 2019.

Assess the Patient’s Experience With Psoriatic Disease • Create a partnership based on trust to foster open dialogue about impact of psoriasis and treatment goals • Treatment selection should reflect patient’s answers to questions such as: ‒ How does psoriasis affect your daily living, including function, sleep, socializing, productivity, intimacy? ‒ What are your symptoms (eg, pain, itching, burning, dry skin), and what are all the areas of your body affected? ‒ What has been your experience with previous treatments? ‒ What do you hope treatment will accomplish? Aldredge LM, Higham RC. J Dermatol Nurses Assoc . 2018;10:189-197; American Academy of Dermatology. www.aad.org/education/basic-derm- curriculum/suggested-order-of-modules/psoriasis. Accessed May 23, 2019; Van Voorhees AS, et al. www.psoriasis.org/sites/default/files/npf_pocketguide_2018_0010.pdf. Accessed April 28, 2020. 14

Most Patients With Moderate to Severe Psoriasis Are Undertreated or Untreated • Data from US National Health and Types of Treatment in Year Prior to September 2012 Wellness Survey and insurance claims, 2007 to 2012 − 1.7 million insured US patients 22% with moderate to severe Topical psoriasis Phototherapy 42% • 59% had not been treated in Traditional oral systemic past year Biologic • Of those treated in past year, 32% 17% of patients taking a 50% were no longer being biologic were also taking a traditional oral systemic treated 3% Armstrong AW, et al. Dermatol Ther (Heidelb). 2017;7:97-109. 15

Patients With Psoriatic Disease Are Dissatisfied With Their Current Treatment: MAPP Survey Biologic Therapy (n = 90) Conventional Oral Therapy (n = 128) 50 50 43.7 40 40 Patients (%) Patients (%) 30 30 25.6 17.8 20 20 16.4 13.3 13.3 10.0 10 10 7.0 6.3 3.9 0 0 AEs/abnormal laboratory tests AEs/abnormal laboratory tests Injection anxiety/fear Laboratory monitoring Injection physical preparation Lifestyle modification Pain/discomfort Lack/loss of effectiveness Inconvenience Inconvenience AE = adverse event; MAPP = Multinational Assessment of Psoriasis and Psoriatic Arthritis. Lebwohl MG, et al. Am J Clin Dermatol. 2016;17:87-97. 16

Case Study (cont’d): Lori’s Physical Exam and Lab Findings • Physical examination • Laboratory findings – Height: 5 ft 4 in – FPG: 121 mg/dL – Weight: 179 lb – A1C: 6.3% – BMI: 30.7 kg/m 2 – Lipids: – Waist circumference: 35.5 in • TC: 215 mg/dL – Blood pressure: 141/91 mm Hg • LDL-C: 128 mg/dL • HDL-C: 47 mg/dL • TG: 260 mg/dL A1C = glycated hemoglobin; FPG = fasting plasma glucose; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein 17 cholesterol; TC = total cholesterol; TG = triglycerides.

Psoriatic Disease: Comprehensive, Collaborative, Patient-Centered Care Primary Care Dermatologist Overall evaluation and Topicals, systemic therapy, management; comorbidities, biologics, refractory disease vaccines, monitoring, education Patient Behavioral Health Rheumatologist Counseling PsA, imaging Pharmacist Medication management 18

Psoriatic Disease and Atherosclerosis: Shared Inflammatory Mediators Psoriatic disease inflammation From endothelial dysfunction to atherosclerosis CRP Liver TNF- α Fibrinogen IFN-  Skin keratinocytes LDL-C Adipose IFN- α + TG tissue IL-1 Inflammatory cells Leptin IL-6 Resistin Skeletal IL-7 MCP-1 muscle Common link Insulin resistance Increased activity Future research of inflammatory Therapies for psoriasis associated with fewer CV events mediators among patients with psoriasis; further long-term study needed CRP = C-reactive protein; IFN = interferon; MCP-1 = monocyte chemotactic protein-1. Adapted from: Gisondi P, Girolomoni G. Semin Thromb Hemostat. 2009;35:313-324. 19 Hugh J, et al. J Am Acad Dermatol . 2014;70:168-177.