Biologics: The Solution for Psoriasis?

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials podcast. I'm John Horton your host. Treatment of psoriasis has dramatically improved over the past two decades, thanks to a class of medications known as biologics. These complex mixtures target overreactions by your immune system that speed up new skin cell development, the mechanism that causes the scaly and discolored skin that defines psoriasis. Biologics have brought results which explains why they're being used more and more to control the condition.

We're joined today by dermatologist Anthony Fernandez, to take a closer look at how biologics are transforming psoriasis care. Dr. Fernandez is one of the many experts at Cleveland Clinic who visit our weekly podcast to help us better understand new health treatments and trends. Now let's find out whether biologics may be the answer for the millions and millions of people living with psoriasis. Welcome to the podcast, Dr. Fernandez. We appreciate you popping in for a chat.

Anthony Fernandez:

Well, thank you, John. Good to see you.

John Horton:

So we're talking about psoriasis, and that's a skin condition that affects an estimated 125 million people around the world. So that's a lot of folks that are looking to science for a solution to a health issue.

Anthony Fernandez:

Yeah, you're right. It's estimated that two to three percent of the entire world's population has psoriasis. So this is definitely a disease that generates a significant amount of suffering around the world. So any scientific breakthroughs in our understanding of the disease or the ability to treat it can translate into tremendous benefits for all of those people who are suffering on a global population scale.

John Horton:

Well, we're going to talk about one of those advances today that I know has really kind of pushed things forward with treatment and that are biologics. And I know it's being used much, much more for treating the condition, particularly in severe cases. But before we get into how that medication works, can you explain exactly what the medication is, what biologics are and where they come from?

Anthony Fernandez:

Biologics are antibodies, and I think most people are probably familiar with the term antibody, but an antibody is a protein that binds to something very specific. And we, our immune system naturally makes antibodies. It makes the antibodies to viruses or bacteria or other foreign substances that are able to invade our body. So the idea is we make an antibody, for example, to a virus so that the next time that virus invades our body, the antibody binds to it and can either incapacitate it or sort of knock it down and target it for the immune to destroy it.

And in fact, that's what vaccinations are. All a vaccine is, is introducing a part of a virus or bacteria into our body and triggering our immune system to react to it. So biologics are antibodies, but instead of specifically recognizing a virus or bacteria or some other foreign substance, these are antibodies that are synthesized in a laboratory and are meant to recognize very specific key components of inflammatory processes. And in the case of psoriasis, of course, to recognize the key components of the inflammatory environment of psoriasis, and in that way sort of knock down all of that inflammation, incapacitate that inflammatory environment.

John Horton:

So it's really fascinating to me how biologics work. They just target things so specifically with psoriasis. Can you walk us through a little bit as kind of how it does that specifically and what it does to the immune system?

Anthony Fernandez:

If you think about the inflammatory environment of psoriasis is sort of being a street gang that's wreaking havoc, that's breaking windows and setting things on fire, beating people up. What biologic medications do is really specifically target those hyperactive gang members and bind to them and sort of tackle them. And because we know so much about the inflammatory environment of psoriasis based on great scientific research, what we've been able to do over the past several decades is really identify the key players, in other words, who are really the leaders of this street gang.

Because if you can take them out, then that whole gang falls apart and you get rid of that chaos and disorder and bring peace back. And that's what biologic medications that we use today do, they really target what we believe are the most important players in that inflammatory environment, bind to them and just incapacitate them. And by doing that, the whole inflammatory environment falls apart and things go back to sort of peace and order.

John Horton:

Dr. Fernandez, I have to tell you, that is one of the best explanations I've heard for how a medication works. And now I'm looking at what's going on in my body in a whole different way with the gang members that are floating around in here doing bad things. So that's amazing that the amount of progress has been made with these medications to zero in that specifically.

Anthony Fernandez:

They're really quite elegant. And I think really it speaks to just the amazing ability of our understanding of molecular biology that not only do we understand the psoriasis inflammatory environment in such molecular detail, but we have the ability to manipulate it and to create safe and effective medications that make patients' lives better despite the fact that they have this disease. It is really amazing. No question.

John Horton:

Yeah. Yeah. Let's talk about how effective they've been. Because I mean, it sounds awesome and it's very cool, but it wouldn't be a big deal if it wasn't working. And it seems like these are really successful, especially with people who have severe psoriasis.

Anthony Fernandez:

Biologics no question have revolutionized our ability to treat patients who have moderate to severe psoriasis effectively. And they are becoming more and more effective as time goes on. So when we think about our traditional systemic medications, medications that really are pills, Methotrexate, Cyclosporine, I would say that when those medications work at their best, if we're getting patients sort of 50% improve compared to where they started before they took the medication, that's great.

Well, with biologics, really the bar has increased significantly. And even the first wave of biologics in the early 2000s, the bar was immediately set at, "We don't think we're doing good unless patients are at least 75% improved from where they started." And as new classes of biologics have come out, that bar has increased even further. So now our goal, if we're not getting patients at least 90% improved or even a hundred percent improved, we don't think we're doing a good job.

So a hundred percent improved of course, means that regardless of what amount of psoriasis they started before taking the medication, it's completely gone after they've been on this medication for some time. And some of our biologic medications now in the clinical trials, 60 to 70 percent of patients will achieve that a hundred percent clearance. So more than one of every two patients who take some of these medicines is expected to completely clear and have no trace of psoriasis on their skin after three to four months of taking these medications. So that's amazing. And I think results that we-

John Horton:

Life-changing.

Anthony Fernandez:

Yeah. Results we didn't even really dream about 50 years ago.

John Horton:

So let me ask you this. So as successful as these are, and everything you just said, as I understand it, biologics are typically not the first treatment option. So why is that?

Anthony Fernandez:

So for patients who have moderate to severe psoriasis, I believe most physicians who treat psoriasis on a regular basis do believe biologic medications should be first line. But we don't always, as physicians get to make the ultimate choice about what patients can take. Insurance companies play a big role in that. And there are a lot of insurance companies who require certain steps or require patients to try certain non-biologic medications before they will approve biologic medications.

And that's unfortunate, but some of it has to do with the fact that these biologic medications are quite expensive. And I think we're always working to figure out ways that will allow our patients to be exposed to biologics earlier when we think those are the best treatment options for them, even as first line treatment.

John Horton:

So given that, who typically is the ideal candidate for biologics treatment for psoriasis?

Anthony Fernandez:

Well, I think there are psoriasis patients who have certain characteristics that will make them ideal candidates. Number one, if they have moderate to severe psoriasis. So certainly patients who have at least 10% of their body surface area involved with psoriasis are ideal candidates for biologics. And we estimate body surface area by thinking about a patient's palm, including their thumb as being 1% of their body surface area. So anything 10 palms worth of psoriasis or more, great candidate for biologic.

John Horton:

Yeah, that's a lot of area.

Anthony Fernandez:

It's actually not.

John Horton:

No? It sounds like a lot when you think about it, but.

Anthony Fernandez:

Well, I think there are a lot of people who, when they envision severe quote unquote "Psoriasis," imagine that a patient has to be covered head to toe in psoriasis. And really when you think about 10 palms worth, it's not that much. And that translates into a lot of research that has shown that patients with just 10 palms worth of psoriasis are a significantly increased risk for having heart attacks and strokes in the future.

So you don't have to be covered head to toe to be severe in nature with your psoriasis. But certainly 10% and you are a great candidate for taking a biologic. I think patients who fail topical medicines, if you fail topical medicines, then you're a good candidate for something that is systemic and biologic medications are as safe and as effective as anything else we have.

And then the other ideal candidates are patients who have psoriasis in what we call sensitive locations, locations that really create a lot of psychological and physical morbidity or that are just hard to treat. So the scalp, the face, the hands, and the palms and the soles specifically and the genital areas. Those are areas where we think about biologics very early in the treatment process.

John Horton:

So how are biologics administered? I'm assuming this isn't just you take a pill.

Anthony Fernandez:

Yes, all biologics, none of them are pills.

John Horton:

Okay.

Anthony Fernandez:

Biologics mostly are administered by subcutaneous injection. There are a few that are given by an IV. And the reason for that is because as we spoke earlier, they're antibodies and you cannot take an antibody as a pill. It's a protein. So if you were to swallow a pill that was packed with antibodies, as soon as it reached the acid environment in your stomach, those acids would just dissolve and destroy the medication.

And even if they survive that, they're too big to sort of penetrate the intestinal wall and get into your bloodstream. So we have to administer them either directly into the bloodstream through an IV or by a subcutaneous injection. Luckily, however, none of them are given on a daily basis, and so the number of injections or the number of infusions that people need on an annual basis are quite low. And that decreases the amount of pain and also the amount of time they need to spend thinking about administering the medications.

John Horton:

Now, are biologics just administered kind of on a schedule and you take them kind of forever and ever after that or is it something you kind of have for a little bit as symptoms come up and then you stop?

Anthony Fernandez:

They are administered on a schedule. So each biologic medication is sort of approved with a dosing schedule. Some are given every three months, some once a month. I never tell a patient that they have to continue these medications forever. I think that's up to the patient. But none of them are cures for disease. So we sort of spoke earlier about the environment of psoriasis is sort of being a street gang that's wreaking havoc.

The reality is when an antibody, a biologic medication sort of binds to one of those gang members, it really just puts a headlock on that gang member. It doesn't kill the gang member. So if patients stop taking biologics and that headlock goes away, the most likely scenario is the psoriasis is going to come back. That street gang is going to start misbehaving again.

But there are patients who sometimes they just need to take breaks and that's okay. Luckily, psoriasis doesn't progress to a life-threatening state. So we have time and patients need to be in charge of their own care. And I think what we're to do is sort of guide them and work with them as part of their care team and not tell them what to do.

John Horton:

Now, medications always seem to come with risks too, especially if you read that fine print down at the bottom. So what are the possible concerns when it comes to taking biologics for psoriasis?

Anthony Fernandez:

I think as medications that affect the immune system, the well-known side effect of all medications is at least a slight increased risk in infection. Now, for a lot of these newer medications, really that slight increased risk really is focused on upper respiratory infections that are mild. One of the first classes that came out, the TNF-alpha inhibitors, those are medications that are known to have increased risk of more serious infection, albeit low.

The newer classes of medications really we haven't seen an increased risk of serious infections that may put someone in the hospital, but that's the biggest. Besides that, it really depends on the class of medication. So the TNF-alpha inhibitors, we know we need to avoid giving them to patients who have diseases like multiple sclerosis because it can affect the central nervous system in some patients.

Interleukin 17 inhibitors, those are medications that we know can trigger nuance that are flares of inflammatory bowel disease. So we try to avoid them in that patient population. So there are nuances depending on the class of biologics. But I think it's important to note that we do believe biologic medications are overall far safer than the systemic medications we had available to us to treat psoriasis before biologics were invented.

John Horton:

Now you mentioned multiple sclerosis. Are there any other kind of existing health conditions you might have that would make biologics not the best idea?

Anthony Fernandez:

And that's really, so the multiple sclerosis really is specific to the TNF-alpha inhibitors.

John Horton:

Okay.

Anthony Fernandez:

And there are, and it really depends again on the class of biologic that you're thinking about for the patient. So for TNF-alpha inhibitors, patients with any strong family history of a demyelinating nervous system disease like multiple sclerosis, we try to avoid those medications. Patients who have known congestive heart failure, it's probably a good idea to avoid TNF inhibitors in those patients as well.

Patients who have chronic infections, unfortunately some people do. Most biologic medications we'd have to be very careful about exposing patients to if they have chronic infections. And then we mentioned the inflammatory bowel disease. So the interleukin 17 inhibitors.

We definitely try to avoid exposing patients with inflammatory bowel disease, either Crohn's disease or ulcerative colitis to interleukin 17 inhibitors. But luckily in today's world, because we have numerous different classes of biologics, regardless of underlying medical conditions that any given patient has, we can usually find biologic medications that we believe will be both safe and effective for those patients in treating their psoriasis.

John Horton:

So this seems like a case where it's important if you're seeing your healthcare provider and looking for one of these, you need to make sure to talk about your entire health picture with them and so that way you get the right biologic for you.

Anthony Fernandez:

Absolutely. I think most of us who prescribe biologic medications for psoriasis believe that it's more important to prescribe a biologic that we believe is going to be safe for the patient as opposed to the one that we think is going to be most effective. We definitely do not want to cause harm with these medications.

John Horton:

I've seen you go online and there's a lot of chatter there where people look at biologics as a potential cure for psoriasis. Is that a little overly optimistic?

Anthony Fernandez:

Yes. These medications are fantastic. They are life-changing to many patients with moderate to severe psoriasis, but we are not at the point where we can say we have any medication that can cure psoriasis. There is a lot of research certainly going on to eventually try to generate a cure for this disease, but unfortunately not quite yet.

John Horton:

We're getting there. So it sounds like we've made so many advances so we can keep moving forward and hoping.

Anthony Fernandez:

Yeah, absolutely.

John Horton:

This whole conversation has been fascinating with what is being done with these treatments and the advances that we've seen, and I really appreciate you giving us a glimpse at just all that's happening with it. But before we part ways, is there anything else you'd like to add on the topic of biologics and just what we can look forward to in the future?

Anthony Fernandez:

Well, I just want to reiterate that biologics have literally revolutionized our ability to treat patients safely and effectively who have psoriasis. And quite frankly, they're the reason why I love treating psoriasis. Psoriasis is one of the most fun conditions that I treat because I know I have these biologic weapons that will make a huge positive difference in our patient's lives. And I think there is a tremendous amount of research that is going on every day, and that is simply going to translate to even better medications, better results, and hopefully one day a cure for psoriasis for those who suffer from it. So it's great times.

John Horton:

Well, I look forward to having you come on whenever that point is so we can talk about the cure and what it's going to do. So thanks again for stopping by and can't wait to have you back on.

Anthony Fernandez:

Thank you very much, John. My pleasure.

John Horton:

Biologics are an increasingly popular and effective way to treat psoriasis, but it's not a treatment for everyone. Talk with your healthcare provider about your options and any new advances that may help you address your skin condition. If you liked what you heard today, please hit the subscribe button, leave a comment to share your thoughts. Till next time, be well.

Speaker 3:

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