Biologic Therapy for Psoriasis: Who’s a Candidate?

P soriasis has a tremendous impact on the lives of patients. New psoriasis treatments are a godsend to those patients for whom previously available treatments have not been effective. But, these treatments do cost more than previously available treatments. With third-party payment for medical services, there is very little incentive for either the patient or their physician to attempt to control the cost of care. Insurers want to know who is an appropriate candidate for these treatments. When payers have a contractual responsibility and obligation to encourage cost-effective treatment, the patient with severe psoriasis presents a challenge. Methotrexate is a very cost-effective treatment, yet it’s associated with serious safety concerns. Now biologics such as alefacept (Amevive), efalizumab (Raptiva), etanercept (Enbrel) and infliximab (Remicade), appear safer than methotrexate, but are far more costly. Cost concerns do not outweigh safety concerns. While patients who fail methotrexate are certainly candidates for the new biologics, there should be no requirement that patients try or fail methotrexate before a biologic therapy be used. Phototherapy — in particular, UVB phototherapy — is another story, though. UVB is effective for many patients, more so when used in combination with topicals (tar, calcipotriene [Dovonex] or tazarotene [Tazorac]) or acitretin (Soriatane). UVB has an unprecedented safety record, and is also far less costly than treatment with new biologics. UVB is far from perfect, however. For many patients, access to UVB phototherapy is a major problem. Many people do not have reasonably convenient access to broadband UV, much less narrowband. Insurers should not require failure of a treatment to which the patient does not have reasonable access. Insurers can, however, encourage greater access to UV through higher reimbursement, elimination of co-pays for UV treatments and coverage of home phototherapy devices. Because of its relative safety, UVB phototherapy should be considered first. But, many patients are not candidates for UVB because of the thickness or inflammatory quality of the lesions, photosensitivity, past failure or inaccessibility to treatment. In these patients, biologic therapies can be considered first-line treatment for severe psoriasis. Biologic therapy for psoriasis is appropriate for patients who have severe disease (as evidenced by more than 5% to 10% of body surface area affected, disabling disease, severe impact on quality of life or significant psoriatic arthritis). Steven R. Feldman, M.D., Ph.D. Chief Medical Editor

P soriasis has a tremendous impact on the lives of patients. New psoriasis treatments are a godsend to those patients for whom previously available treatments have not been effective. But, these treatments do cost more than previously available treatments. With third-party payment for medical services, there is very little incentive for either the patient or their physician to attempt to control the cost of care. Insurers want to know who is an appropriate candidate for these treatments. When payers have a contractual responsibility and obligation to encourage cost-effective treatment, the patient with severe psoriasis presents a challenge. Methotrexate is a very cost-effective treatment, yet it’s associated with serious safety concerns. Now biologics such as alefacept (Amevive), efalizumab (Raptiva), etanercept (Enbrel) and infliximab (Remicade), appear safer than methotrexate, but are far more costly. Cost concerns do not outweigh safety concerns. While patients who fail methotrexate are certainly candidates for the new biologics, there should be no requirement that patients try or fail methotrexate before a biologic therapy be used. Phototherapy — in particular, UVB phototherapy — is another story, though. UVB is effective for many patients, more so when used in combination with topicals (tar, calcipotriene [Dovonex] or tazarotene [Tazorac]) or acitretin (Soriatane). UVB has an unprecedented safety record, and is also far less costly than treatment with new biologics. UVB is far from perfect, however. For many patients, access to UVB phototherapy is a major problem. Many people do not have reasonably convenient access to broadband UV, much less narrowband. Insurers should not require failure of a treatment to which the patient does not have reasonable access. Insurers can, however, encourage greater access to UV through higher reimbursement, elimination of co-pays for UV treatments and coverage of home phototherapy devices. Because of its relative safety, UVB phototherapy should be considered first. But, many patients are not candidates for UVB because of the thickness or inflammatory quality of the lesions, photosensitivity, past failure or inaccessibility to treatment. In these patients, biologic therapies can be considered first-line treatment for severe psoriasis. Biologic therapy for psoriasis is appropriate for patients who have severe disease (as evidenced by more than 5% to 10% of body surface area affected, disabling disease, severe impact on quality of life or significant psoriatic arthritis). Steven R. Feldman, M.D., Ph.D. Chief Medical Editor