Expert Perspective on the Management of Psoriatic Arthritis - Episode 5
Currently available non-biologic and biologic therapies used to treat psoriatic arthritis and guidance regarding proper treatment selection and use.
Lana Dykes: Can you discuss available nonbiologic treatments for psoriatic arthritis, starting with methotrexate?
Christopher Parker, DO: Sure. I started practicing rheumatology in the 1900s. I’ve been around awhile. Back then, nonbiologic therapies were good in some ways but bad in others. We did not have nearly as many options, but we did have methotrexate. I’ve had wonderful success with it. Of course, it didn’t always work either. It’s not FDA approved, and I understand that. But it is a drug that I think the vast majority of rheumatologists are comfortable using. And even though it’s not a medicine I feel like I need to start with these days, at all, it’s in my toolbox for situations when I feel like it’s needed.
Apremilast is FDA approved, and I’m happy to report that. Very commonly, apremilast is a first-line therapy once I get past normal nonsteroidal anti-inflammatory drugs. I want the patient to understand that this medicine is FDA approved for both skin psoriasis and the musculoskeletal manifestations of the illness. I talked about enthesitis earlier, and sausage digits, and arthritis. And so, I want to try to do all the work with just 1 medicine, if you will, instead of having to use a completely different drug, for example, for skin problems or something like that. So again, it’s commonly a starting medication for me for a variety of reasons. No. 1, it’s FDA approved. No. 2, I have had many great experiences with it. Again, patients want to understand that. No. 3, the safety profile of this medication is magnificent.
Before it was FDA approved, I had the opportunity to look at the safety data, and I was like, “Wow!” I didn’t really need to do laboratory monitoring over time, which I am so used to doing. And there were no differences in the infection rates against placebo, or cancer rates, and other things that we’re used to seeing come out of a phase 3 trial. So it was exciting to have a medicine in my toolbox that I could give to patients, particularly in my neck of the woods, in Austin, and probably many places in the United States, who just want to solve their problems with dietary modification and some vitamins and maybe some turmeric and other so-called natural things. And so, when I talk about a medication like this and its safety profile, they’re more accepting of something that doesn’t come with a lot of lab monitoring requirements and stuff like that. Again, it’s a commonly employed therapy both because of efficacy and safety.
Lana Dykes: In your clinical practice, when apremilast is used, is it used as a monotherapy or in combination with other agents?
Christopher Parker, DO: Yes. Either one. I definitely use it as monotherapy, and I definitely use it in combination. Again, that is one of the advantages of a medication like this. It plays nicely with others when needed. I’ve had the experience where someone needed more help. I put something else in to really get that good control and that patient said, “Yes, now I’m happy.” I can look at a situation like that and say, “Great, I’m happy. And the lab’s happy. And the imaging; everybody’s happy.” That’s what I’m looking for.
Lana Dykes: What are some of the available biologic treatment classes for managing psoriatic arthritis?
Christopher Parker, DO: Again, compared to the 1900s when we had so few…we didn’t have any biologics back then, actually. I grew up in the prebiologic era. Then, we got TNF [tumor necrosis factor] inhibitors. Then more recently, we’ve seen IL-17 [interleukin-17] and IL-23 and a T-cell inhibitor. We’ve got all kinds of different biologic classes. Again, it’s nice to have lots of different tools in the toolbox. There’s no one-size-fits-all, which my patients totally understand and they don’t feel like it has to be done on the first try. But, I will share that if I have years and years of good experience with a particular medication, or class of medication, whatever the case may be, I share it with them. I tell them so they have that comfort. And so, I’ll select things that I have many years of good experience with over a medicine that’s brand new. I realize there are some minds out there that think, “Oh, newest technology must be best.” But in my mind, it’s hard to beat tried and true if you’ve really had many, many great experiences with something. And so, I like patients to understand that balance and difference.
Transcript edited for clarity.