Tailoring Psoriasis, Psoriatic Arthritis Treatment to the Patient: Philip Mease, MD

Psoriatic arthritis (PsA) affects roughly 30% of patients with psoriasis, yet no 2 cases look alike, says Philip Mease, MD, director of rheumatology and research, Providence Swedish Medical Center, and clinical professor, University of Washington.

This transcript was lightly edited; captions were auto-generated.

Transcript

With the growing number of topical and systemic therapies for psoriasis and psoriatic arthritis, how do you approach selecting the most appropriate treatment for patients?

We are blessed with a number of different medications that are now available to us to treat psoriatic arthritis and psoriasis. My focus as a rheumatologist is primarily on psoriatic arthritis, which occurs in about 30% of all patients with psoriasis. One of the issues that we have with PsA is that it is very heterogeneous in its clinical presentation. A patient can have arthritis; enthesitis, where tendons and ligaments insert into bone; spondylitis, involving the spine; and dactylitis, involving a whole digit, in addition to psoriasis and nail disease.

What we end up doing is identifying what are the key issues that the patient is facing. Is it primarily their skin disease? Is it primarily their joint disease? Is it primarily their spine disease? And there needs to be some tailoring of choice of medications based on this profile. What we do is we talk all of this over with the patient and also give them choices between injectable medicines, oral medications, and intravenously infused medications, and then coming up with what their preference is and then matching that to what their insurance company is dictating in terms of which medicine might best be used at what stage. It's a complex interplay of all of those things that go into making the decision about what best to use.

How are recent insights into the immunology and genetics of psoriasis influencing your clinical decision-making, and which emerging therapies do you see having the biggest impact in the next few years?

We've learned a lot about the immunology and genetics of psoriasis and psoriatic arthritis, and primarily it's the immunology that helps dictate what is effective in medications. We know that, for example, the interleukin-17 and interleukin-23 pathways are highly important, not only in psoriasis but also in the musculoskeletal aspects of the disease; we know that the TNF [tumor necrosis factor] pathway is an important one, and so we also have learning that the Janus kinase pathway is important, and more are coming.

For example, we're about to start on a trial with a TL1A inhibitor, so [we’re] all the time learning about new targets for treatment. What we end up doing is selecting medicines from the choices that we have that target 1 or more of these pathways, knowing that when you target one, there's often spillover into targeting others, and so it's by this means that we end up making our choices based on the basic biology and immunology of the disease.