Transcript
Brad Glick: We may have touched on this already, but I just want to reiterate what your thoughts are as to what is an appropriate therapeutic trial. Now we've kind of alluded to that in the setting of use of antihistamines, and not to get too much on guidelines, but the recent European guidelines would say minimum therapeutic trial of two weeks, two to four weeks, maybe one goes a little bit longer than that, but not much more. But now you have an individual in clinic and they've been on one of the three FDA approved therapies. At what point do you decide that you're going to change therapy?
Laura Ferris: It depends a little bit on the treatment. Remibrutinib, it's so quick and works very well for patients that if they came to me at 12 weeks without a response or even at eight weeks without seeing any response, I'm a little bit less excited about going on. On the other hand, if I have dupilumab or omalizumab, and maybe they're seeing a little bit of response, but not at goal in two months, I'm going to encourage that person to keep going. I'm going to also try to layer on other therapies, maybe keep on those four antihistamines while we're doing that, if that was the right drug for that patient.
The other reason why I think speed, I know we kind of touched on this, but why speed is so important is that what happens when your CSU patient goes to urgent care or they go to their primary care doctor, they get prednisone, and then their hives go away and they're like, "This is a miracle. I just need to stay on prednisone all the time." And they'll keep going around you to get more prednisone. And we know that that's just not a safe long-term option. So to be able to say, "I've got another drug, it's oral also, it's quick also, but it's so much safer for you and it's actually a long-term option unlike the prednisone." So I always, in the back of my mind, I feel like I'm competing with prednisone even though it wouldn't be me giving it.
Brad Glick: It's so true. And you brought up a really good point also that if our patients are coming in and they're on antihistamines, dose escalated or not, we also need to tell them that none of the drugs are completely perfect in terms of their therapeutic outcomes. If they stay on the antihistamines, we can get to a point over time in weeks or months where maybe we would decide to take a little bit of a drug holiday probably from the antihistamine, first. This brings to mind for me, we've got three great drugs in the toolbox, we're combining them with antihistamines. I think one of the things I've learned since we've had these drugs back in the toolbox that having to go to that rescue corticosteroid, you brought up a very important point that we might reach to it periodically, but certainly it's about maintenance.
And I think that that's important from an educational standpoint, not only just in this setting and for our colleagues, but for our patients that you don't want to get stuck on corticosteroids because we have these great therapeutics in the toolbox. But how do we get it all back? I mean, how do we bring this back into our clinic and take more ownership of this disease state? And we can make this kind of our last words, Dr. Green.
Lawrence Green: So, just like we brought a lot of other things back, we're bringing HS back, like we said at the beginning, it's time to bring this back because it's a very simple thing to do. It's not complicated. It's not allergy related. We don't have to do a big workup. There are over-the-counter medicines the patient can try and it's not working. We have FDA approved products, medicines. We have an oral medicine as well as an injectable medicine we've been using for years and years that we're all comfortable with. There's no reason not to bring this back home.
Laura Ferris: It's a disease of the skin ultimately, and so it should be our disease. And we do have great options. We have great options that are safe and effective and simple for us to use. And there's also, we talked about the fact that we don't need to do allergy testing. I'm going to also say there's a little harm to doing allergy testing because people get RAST testing, all of a sudden they see oak pollen and milk, even though maybe they've been drinking milk without problems their whole life, and they start driving themselves crazy with trying to avoid things. I think we could actually impair their quality of life when they start going down the wrong pathway. So by keeping this skin disease in dermatology, we can get our patients better and we are the ones who can give them the best guidance. I really believe that.
Brad Glick: I don't think we could end this on better words. So to both of you, Dr. Green, Dr. Ferris, thank you so much for an exceptional conversation about how we take back CSU into our clinics as dermatologists. So, thank you all, and thanks for another episode from Practical Dermatology Roundtable.