Exploring the Future of Psoriasis Treatment with Oral Agents

Announcer: 
This is DermConsult on ReachMD. On this episode, we’ll hear from Dr. Christopher Bunick, Associate Professor of Dermatology at the Yale School of Medicine in New Haven, Connecticut. He’ll be discussing the future of personalized care for psoriasis.

Here’s Dr. Bunick now.

Dr. Bunick:
Personalized can mean having more options that fit patient needs, in terms of having more oral therapies that have or approach biologic-like efficacy. I think that’s where we’ve had a huge gap. So that personalized ability to work with patients that really prefer an oral option but want that higher efficacy, we’re going to have that now, both with zasocitinib and the icotrokinra that’s coming, the cyclic IL-23 receptor peptide. And I do think that one of the emerging developments in psoriasis as a whole is this oral space. And what we don’t know and what is going to be the emerging development over the next year or two is how these therapies play out between zasocitinib, a cyclic IL-23 receptor peptide inhibitor, as well as a apremilast, which shows no signs of going anywhere as tried and true and, arguably, beloved among many dermatologists—this PD-4 inhibitor apremilast.

So I think that we’re going to have three strong oral therapies in the plaque psoriasis space, and how they play out will largely depend on, I think, provider experience in the real world. There’s been a lot of emphasis about real-world data across all of dermatology diseases, and I think that when we think about personalized psoriasis care, some of the real-world experience with these new oral agents is going to be incredibly important. What we do know, again, is that the evidence-based medicine strongly suggests these therapies are superior to apremilast in terms of efficacy. And therefore, it’ll be interesting to see in the real world, does that play out? Is that what patients are going to say? “This works best. This feels best. This is safe. I like this.”

When we think about pharmacogenomics, there’s been some development of tests to try to identify which classes of therapies would work best for psoriasis patients. For example, TNF alpha inhibitor versus IL-23 inhibitor versus IL-17. At least to my knowledge, I haven’t seen that testing really take hold amongst the dermatology community, and I think part of that reason is that when you have such high-efficacy therapies in that IL-17 and IL-23 class, for most patients, you can almost flip a coin and they’re going to do really well with either the first or second choice you make. And I think that the need to try to drive and understand the pharmacogenomics at the molecular level at the bedside in psoriasis is not quite as high as maybe what people thought it would be.

So I do think that’s where the personalized psoriasis care can go is going to be less about your traditional plaque psoriasis, where the therapies work really well—we’re talking PASI 90/100 at really high rates—but where I do think the personalized psoriasis application can go is in these other subtypes that are more rare, where you don’t always know what is the major driver. So when we think about, for example, the relative proportion of IL-23 or IL-12 or type I interferons in some of these paradoxical reactions, that’s where I do think the personalized pharmacogenomic toolkit, for example, could be applied to better understand what therapies might work for those types of psoriasis patients.

Announcer:
That was Dr. Christopher Bunick discussing next steps in personalized treatment for psoriasis. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!