February 15, 2019
Steven Feldman, MD, PhD, professor of dermatology at the Wake Forest School of Medicine, discusses costs associated with psoriasis drugs and focuses specifically on the impact these costs have on insurers.
Hi, I'm Dr. Steve Feldman, professor of dermatology here at the Wake Forest School of Medicine. I specialize in the treatment of patients with psoriasis. Today I want to talk about the cost of psoriasis drugs with special focus on the impact that that cost has on the insurers.
First let me just say that psoriasis has an enormous impact on patients' lives. Research that we did here at Wake Forest showed that the impact of psoriasis is as great on patients' lives or greater than other major medical conditions like diabetes and heart disease. Fortunately we have a lot of treatments that can help control psoriasis now.
Psoriasis presents in various ways and so I want to separate the discussion of cost into two groups. There's the patients who have relatively mild psoriasis where we can treat them with topical therapies ‑‑ creams, ointments, sprays, things like that ‑‑ and people who have more extensive psoriasis that need treatment to the whole body at once, either with phototherapy or systemic medication.
Let's talk about mild psoriasis first. The vast majority of patients with psoriasis have relatively limited disease. Just a few percent of their body or less covered with the disease, and they're suitable for the treatment with topical therapy. The topicals usually are topical cortisone medicines ‑‑ the super‑strong ones typically, like clobetasol.
Vitamin D analogues can be used. They don't have cortisone side effects but they're not as effective. When we use them we use them in combination with the topical steroids.
You're familiar with patients not taking their medicine. That happens throughout all of medicines with pills and things, but adherence to topical therapy is even worse. It's very typical for us to try to keep the regimen simple and to use treatments that patients don't mind using.
That's why topical cortisone spray products, like a clobetasol spray, or a combination of a steroid with a vitamin D analogue like the betamethasone/calcipotriene combination were real advances in our management for mild psoriasis.
Unfortunately, the cost of generic medications has been going crazy lately, so even generic topical corticosteroids have become expensive drugs for some crazy reason. Ideally, if an insurer has any super‑strong generic corticosteroid available for my patients with psoriasis, that would be great.
I don't have a particular preference for one molecule over the other, has long as I have a high‑strength steroid, that's great. If I can have it available to me and my patients in a couple different vehicles at low cost ‑‑ for example, an ointment for patients who are willing to put something greasy on their skin, a spray for those who aren't, that would be pretty much an ideal situation for me.
Most of the interest and excitement about psoriasis management now, especially the cost of psoriasis management, relates to biologic therapy, because biologics are highly effective psoriasis, but they're also extremely expensive, costing tens of thousands of dollars per year.
Biosimilars are coming and they may help reduce the cost somewhat, but they're not here yet, and I suspect that even when they are approved, at least at first, they're still going to be relatively high‑cost products.
The tumor necrosis factor inhibitors were our first major leap quantum forward in the management of psoriasis. These are drugs like etanercept and adalimumab. We have drugs that I believe are...well, certainly more effective and possibly even safer in the form of interleukin‑17 and interleukin‑23 inhibitors. Having those available to my patients would be ideal.
If an insurer had some other biologic ‑‑ say, adalimumab or a particular IL‑23 drug available at lower cost ‑‑ it would not necessarily be unreasonable to encourage patients to try that first, because all of these drugs are so good and so effective.
I think the big opportunity for helping minimize exposure to biologics is encouraging patients to try ultraviolet light phototherapy for psoriasis. Phototherapy can be highly effective and can be very inexpensive. Patients can get ultraviolet light treatments in a physician's office, or they can get a home light unit.
A home light unit that potentially could help control patients' psoriasis for a lifetime might cost less than the first month or two of a biologic. It might not be unreasonable to strongly encourage patients to try home light therapy for their psoriasis.
Unfortunately, because home phototherapy falls under the durable medical equipment side of insurance, it often costs patients much more to get a home phototherapy unit than to try a biologic, especially with all the programs that the manufacturers have for reducing the cost of biologics to patients.
I think if I were running the insurance system, I would not only make it low‑cost to get home phototherapy. I'd probably find a way to pay the patients' costs for the delivery and installation of the device. I'd probably consider paying and encouraging patients to take the time to go for office phototherapy if it would help me keep patients off of biologics.
Finally, the last thing I wanted to point out is we have a tremendous resource for educating ourselves and our patients about psoriasis and its management. That's our National Psoriasis Foundation. The Psoriasis Foundation has materials on all the different treatment options to educate patients about choices of biologics, other systemic therapies, as well as phototherapy. You can access all the National Psoriasis Foundation resources at www.psoriasis.org.
I hope you've found this discussion of the cost of psoriasis helpful. Again, I'm Steve Feldman, professor of dermatology at Wake Forest School of Medicine. Thank you so very much.