- Friday, November 17, 2023
- Allison Truong, MD, FAAD
- Expert Insights, Psoriasis Around the World, Research, Treatment
THE 101
- Psoriasis therapies evolve, but patient adherence is crucial for optimal outcomes.
- Nonadherence to treatments impacts health care systems and patients’ overall health.
- Topical therapies are mainstays with adherence challenges; oral agents, biologics, and phototherapy are alternatives.
- Oral agents face suboptimal persistence; in real-world data, apremilast vs. methotrexate saw discontinuation rates of 69% vs. 59% in the first year.
- Biologics generally have higher persistence and adherence rates, with a persistence rate of over 70% in various regimens.
- Phototherapy, despite assumptions of low adherence, may benefit from the “white coat effect.”
Psoriasis Therapies and Patient Adherence
Psoriasis therapies continue to evolve and improve; nevertheless, not all patients are better, even when on the best treatments. Patient adherence is often necessary for the maximum efficacy of a treatment to be seen. Yet, studies show that patients are only adherent 50% of the time in the setting of chronic diseases.1 Nonadherence leads to considerable financial losses to the health care systems and directly impacts patients’ overall health and quality of life.2 Thus, understanding patients’ adherence to psoriasis treatments will help clarify the need to change treatment algorithms or maintain the same treatment while encouraging patients to be more persistent and consistent with their regimens to get the best possible result.
Treatment Options and Challenges
Topical therapies maintain the mainstay of psoriasis treatments with limited side effects, yet patients continue to struggle with adherence. In an eight-week clinical trial in psoriasis patients, overall adherence decreased from 84.6% to 51% within the treatment period.3 Therefore, non-topical therapies such as oral agents, biologics, and phototherapy are available for those with more widespread disease and/or those who suffer from poor quality of life from their disease. Oral agents used for psoriasis include methotrexate, acitretin, cyclosporine, apremilast, tofacitinib, deucravacitinib, and upadacitinib. Biologics include etanercept, infliximab, adalimumab, certolizumab, golimumab; anti-IL17: secukinumab, ixekizumab, brodalumab, bimekizumab; anti-12/23: ustekinumab; anti-IL23: guselkumab, tildrakizumab, risankizumab; anti-CTLA4: abatacept. Phototherapy can be administered as psoralen-UVA (PUVA), narrowband UVB (NBUVB), broadband UVB (BB-UVB), and excimer laser. Despite hopes that these alternative treatments may perform better adherence than topicals, real-world data suggests they also experience suboptimal adherence worldwide.
Challenges with Oral Systemics and Biologics
Oral systemics are popular among patients with needle phobia, but patients tend to have less than optimal persistence and adherence to these agents. Persistence measures the continuing use of a prescribed therapy versus adherence, which refers to the extent to which a patient follows a prescribed regimen. For oral agents, patients tend to stop taking them within the first year, possibly due to their lower efficacy and side effects within the initial starting period.5 In real-world data in France on the persistence of oral agents, apremilast versus methotrexate, 69% of apremilast and 59% of methotrexate discontinued the treatment within the first year.4 Similarly, an observational study in Japan showed a 50% persistence of oral agents (apremilast, cyclosporine, methotrexate, and etretinate).5 In the United States, Armstrong et al. evaluated over 82,621 psoriasis patients, and among the 16,000 patients who received methotrexate, acitretin, cyclosporine, or apremilast, the adherence rate was 45.2%.6
Dynamics of Biologic Treatment
In comparison, biologic agents typically have higher persistence and adherence rates than any other psoriasis treatment, yet rates remain suboptimal and vary depending on available studies.7 Biologics are fast, effective, and have few side effects, but some patients may discontinue or switch therapies due to loss of efficacy and high costs. In the Japanese study described above, the persistence of biologics was greater than 70% for patients on the following regimens: adalimumab, infliximab, certolizumab pegol, ustekinumab, guselkumab, risankizumab, tildrakizumab, secukinumab, brodalumab, and ixekizumab.5 Similarly, in Germany, using a claims database, the persistence rate of biologics was 56%, with the highest rate being ustekinumab at 80%.8 In terms of adherence, Armstrong. et al. showed an adherence rate of 53.1% for biologics in the United States.6 Comparably, in a 24-month retrospective study of patients treated with ixekizumab or adalimumab, ixekizumab had statistically higher adherence than adalimumab.9 The combined data suggests that biologics (anti-IL17 and anti-IL12/23) with less frequent injections may be easier for patients and, therefore, have a higher persistence and adherence than their anti-TNF counterparts.
Adherence Patterns in Phototherapy
Beyond orals and biologics, phototherapy continues to be utilized in psoriasis treatment algorithms for its minimal side effects. Studies are limited in adherence to phototherapy in psoriasis patients. In a study of 818 eligible patients for several chronic dermatologic conditions, including psoriasis, adherence to in-office NBUVB treatment was about 71%, with the highest adherence in patients with mycosis fungoides, at 77%.10 It may be assumed that adherence to in-office phototherapy may be low since phototherapy may be time-consuming, expensive, and inconvenient. Yet, phototherapy appears to have high adherence, possibly from the “white coat effect.” In studies with topicals, patients often demonstrate increased use when they know they are nearing their in-office appointment dates.3 A study on combined treatment with acitretin and NBUVB three times a week for 12 weeks demonstrates that patients adhere to phototherapy, but their adherence to acitretin steadily declined.11
Long-term Disease Management and Patient Adherence
Patients with psoriasis require chronic lifelong disease management, and thus, adherence plays a crucial role in whether they get better or worse over time. More real-world studies are needed to understand to what degree patients adhere to different treatments and what factors lead to treatment discontinuation or patient nonadherence. Practitioners should be aware that flares while on treatment may not be due to the regimen itself but possibly to other patient-related factors. Addressing patients’ concerns and reasons for stopping or not adhering to treatment will allow practitioners to offer the best treatment regimens while decreasing health care cost utilization and improving patients’ overall health.
References
- Interventions for Helping Patients to Follow Prescriptions for Medications. Haynes RB, McDonald H, Garg AX, Montague P. Cochrane Database Syst Rev. 2002;(2):CD000011.
- Medication Compliance: A Healthcare Problem. Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shevlin N. Ann Pharmacother 1993;27:S1-24.
- Adherence to Topical Therapy Decreases During the Course of an 8-week Psoriasis Clinical Trial: Commonly Used Methods of Measuring Adherence to Topical Therapy Overestimate Actual Use. Carroll CL, Feldman SR, Camacho FT, Manuel JC, Balkrishnan R. J Am Acad Dermatol. 2004 Aug;51(2):212-6.
- Persistence of Apremilast in Moderate to Severe Psoriasis: A Real-world Analysis of 14 147 Apremilast- and Methotrexate-naive Patients in the French National Health Insurance Database. Sbidian E, Billionnet C, Weill A, Maura G, Mezzarobba M. Br J Dermatol. 2020 Mar;182(3):690-697.
- Treatment Patterns, Healthcare Resource Utilization, and Costs in Patients with Moderate to Severe Psoriasis Treated with Systemic Therapy in Japan: A Retrospective Claims Database Study. Tada Y, Kim H, Spanopoulos D, Habiro K, Tsuritani K, Yamada Y, Mandal A, Zhong Y, Hikichi Y. J Dermatol. 2022 Nov;49(11):1106-1117.
- Real-world Health Outcomes in Adults with Moderate to Severe Psoriasis in the United States: A Population Study Using Electronic Health Records to Examine Patient-perceived Treatment Effectiveness, Medication Use, and Healthcare Resource Utilization. Armstrong AW, Foster SA, Comer BS, Lin CY, Malatestinic W, Burge R, Goldblum O. BMC Dermatol. 2018 Jun 28;18(1):4.
- Adherence and Resource Use Among Psoriasis Patients Treated with Biologics. Aleshaki JS, Cardwell LA, Muse ME, Feldman SR. Expert Rev Pharmacoecon Outcomes Res. 2018 Dec;18(6):609-617.
- Drug Survival of Biological Therapies for Psoriasis Treatment in Germany and Associated Costs: A Retrospective Claims Database Analysis. Mahlich J, Alba A, Hadad LE, Leisten MK, Peitsch WK. Adv Ther. 2019 Jul;36(7):1684-1699.
- Healthcare Resource Utilization and Costs Among Patients with Psoriasis Treated with Ixekizumab or Adalimumab Over 2 Years of Follow-up in Real-world Settings. Blauvelt A, Shi N, Murage MJ, Kern SA, Somani N, Burge R, Ridenour TL, Lew CR, Zimmerman NM, Zhu B. J Med Econ. 2022 Jan-Dec;25(1):741-749.
- Predictors of Adherence to Narrowband Ultraviolet B First-month Treatment Dosage Plan. Pavlotsky F, Alkhazov A, Barzilai A, Scope A. Isr Med Assoc J. 2022 Dec;25(12):820-823.
- Adherence to Acitretin and Home Narrowband Ultraviolet B Phototherapy in Patients with Psoriasis. Yentzer BA, Yelverton CB, Pearce DJ, Camacho FT, Makhzoumi Z, Clark A, Boles A, Fleischer AB Jr, Balkrishnan R, Feldman SR. J Am Acad Dermatol. 2008 Oct;59(4):577-81.
