Patient Preferences for Biologicals in Psoriasis: Top Priority of Safety for Cardiovascular Patients

Real-World Experience of Patient-Relevant Benefits and Treatment Satisfaction with Apremilast in Patients with Psoriasis: An Analysis of the APPRECIATE Study

INTRODUCTION

In the real-world APPRECIATE study (NCT02740218), most patients with psoriasis demonstrated notable improvements on disease severity measures and reported clinically meaningful treatment benefits with apremilast.

OBJECTIVE

We aim to further describe patient-relevant needs and benefits and patient satisfaction with apremilast, including subgroup analyses based on patient characteristics.

METHODS

APPRECIATE, a multinational, retrospective, cross-sectional study, enrolled patients with chronic plaque psoriasis who started apremilast according to the European label. Patient Benefit Index (PBI; range 0 (no patient-relevant benefit) to 4 (maximum patient-relevant benefit), global PBI score ≥ 1 indicating minimum patient-relevant benefit and ≥ 3 indicating high benefit) and nine-item Treatment Satisfaction Questionnaire for Medication (TSQM-9; range 0-100) were assessed 6 (± 1) months after apremilast initiation and summarized descriptively. Relationships between global PBI and TSQM-9 assessments were analyzed by Pearson correlations.

RESULTS

Of 480 enrolled patients, 347 (72.3%) had remained on apremilast at 6 (± 1) months; 90.9% (300/330) achieved global PBI score ≥ 1. Mean (standard deviation) global PBI score was 2.8 (1.2). Higher achievement of global PBI score ≥ 3 was observed in patients with no prior treatments (61.1% (22/36)) or prior phototherapy (64.6% (42/65)) versus prior conventional systemic (54.4% (100/184)) or biologic (38.6% (17/44)) treatment. Strong correlations were observed between the global PBI score and the TSQM-9 global satisfaction and effectiveness subscale scores.

CONCLUSION

Patients continuing apremilast for 6 (± 1) months in APPRECIATE reported patient-relevant treatment benefits. Findings suggest that receiving apremilast earlier versus later in treatment management is consistent with greater improvements in patient-relevant treatment outcomes.

Exploring determinants of psoriasis patients' treatment choices: a discrete-choice experiment study in the United States and Germany

BACKGROUND

Biologic psoriasis treatments are differentiated by efficacy, side effects, and other attributes.

OBJECTIVE

Determine attributes of biologic psoriasis treatments that drive patients' treatment choices.

METHODS

Respondents (USA: n = 300; Germany: n = 300) with moderate-to-severe psoriasis completed a discrete-choice-experiment survey, choosing between hypothetical treatments characterized by attributes with varying levels: chance of clear skin after 1 year, number of first-year treatments, first-year risks of mild-to-moderate injection site reaction (ISR) and serious infection, and years of proven efficacy/safety.

RESULTS

U.S. respondents most valued clear skin (conditional relative importance, 1.88; p < .05). While other attributes were of generally equivalent importance, ISR risk outweighed serious-infection risk (1.06 vs. 0.70; p < .05). German respondents placed greatest importance on ISR risk (1.61; p < .05) and clear skin (1.49; p < .05).

LIMITATIONS

Respondents evaluated hypothetical treatments and were recruited from web panels.

CONCLUSIONS

Clear skin and ISR risk are stronger drivers of treatment choice than injection frequency and infection risk.

Impact of clinical and demographic characteristics on patient preferences for psoriasis treatment features: Results from a discrete-choice experiment in a multicountry study

OBJECTIVES

This study aimed to elicit preferences for psoriasis treatment features and to test for preference heterogeneity across groups of respondents.

MATERIALS AND METHODS

A discrete-choice experiment was employed to elicit preferences of patients with plaque psoriasis in multiple countries. The survey instrument included a series of choice questions between three hypothetical treatments, each characterized by varying levels of six attributes (namely, lesion reduction, risk of impairing side effects, time to reach results, mode and frequency of administration, itching reduction, and side effects). Random parameters logit was used to model the data. Results were compared across a total of 18 subgroup sets.

RESULTS

The data analysis from 1,123 respondents showed that, on average, respondents receive more utility gain from higher levels of lesion reduction and lower risks of impairing side effects than changes in other attributes included in the study. Systematic differences were detected for 13 sets; the most pronounced differences were observed based on disease severity, nail psoriasis, biologic experience, and quality-of-life scores.

CONCLUSION

These many sources of preference heterogeneity identified by our analysis suggest that to improve patient satisfaction and, probably, adherence and persistence, clinicians should discuss options with patients when prescribing their treatment.

An update on the impact of depression on the treatment of psoriasis

Introduction: Estimates of the prevalence of comorbid depression vary, ranging from 9 and 62%. Deterioration of mental health may emerge as a result of psoriasis; however, it is theorized that depression alone may independently predispose patients to new-onset psoriasis.Areas covered: The aim of this brief review is to explore the impact of depression on psoriasis treatment.Expert opinion: The two studies that directly assess the role of depression in psoriasis treatment outcomes are important, as unaddressed depression can undermine the success of a given treatment. This may reflect the notion that depressed individuals are less likely to be adherent. Thus, it may be valuable for clinicians to not only screen for depression, but to ensure that it is adequately treated. Our knowledge of treatment preferences in psoriasis patients with comorbid depression is limited. Expanding our understanding of preferences may allow providers to better align their recommendations to ultimately increase adherence. Additionally, given that many psoriasis treatments have an impact on depression, it may be beneficial for clinicians to evaluate patients for psychiatric risk factors to optimize the treatment regimen.

The importance of understanding patient and physician preferences for psoriasis treatment characteristics: a systematic review of discrete-choice experiments

Introduction: Treatment adherence continues to be a major challenge in psoriasis. Patient preference studies, especially discrete-choice experiments, are gaining popularity to gather insights into patient reported treatment outcomes. This systematic literature review aimed to critically assess all discrete choice experiments exploring patients' and physicians' preferences for psoriasis treatment characteristics.Methods: PubMed and EMBASE databases were searched using keywords "psoriasis" and "preferences" to identify relevant literature. Discrete-choice experiments conducted in French or English from the year 2000 onwards, that focused on evaluating psoriasis treatment preferences in patients and/or physicians, were included. The relative importance of treatment attributes was assessed and studies were critically appraised using validated checklists.Results: Out of 987 articles identified, 25 articles fulfilled the inclusion criteria. Overall, patients and physicians prioritize efficacy-specific outcomes. Patients are shown to place greater importance to process attributes when compared to physicians, especially route and location of administration. Physicians focus primarily of efficacy attributes, however when the top two attributes are considered, safety outcomes increasingly become considered important. Of the studies, 60% conducted subgroup analysis, of which many reported associations between specific patient characteristics and preferences. Factors such as age, disease severity, and duration of condition significantly affected preferences for treatment attributes.Conclusions: This review provides insight into the types of attributes that patients and physicians value most, and therefore can help improve shared decision-making. The findings of this study also encourage regulatory agencies to continue integrating patient preferences in their decision-making.

Recommendations for Initiating Systemic Therapy in Patients with Psoriasis

Psoriasis is a chronic, systemic, inflammatory disease that is often associated with serious comorbid conditions such as cardiovascular disease, obesity, and diabetes. Many patients with moderate-to-severe psoriasis receive either no treatment or receive topical therapy only and report dissatisfaction with treatment, poorly managed symptoms, and continued impact of the disease on quality of life. Patients currently receiving topical monotherapy can benefit from systemic therapies, which are more effective in reducing clinical symptoms, achieving treatment efficacy targets, and improving quality of life. An array of systemic treatment options with varying mechanisms of action are available, including conventional and newer oral systemic agents and biologics. Each option presents a unique set of benefits, safety risks, dosing schedules, and monitoring requirements. The aim of the current review is to better optimize treatment outcomes in patients with psoriasis by presenting a rationale for when to consider systemic therapy in this patient population. The authors discuss the barriers to use of systemic agents and highlight the central importance of each patient's perspective when assessing disease severity. Additionally, practical strategies for selecting and safely initiating systemic therapy to optimize the treatment of patients with psoriasis are identified.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

Patient and physician preferences for attributes of biologic medications for severe asthma

OBJECTIVE

Despite the increased availability of biologic treatments indicated for severe asthma, patient and physician preferences for these medications remains largely unknown. The purpose of this study was to understand perceptions of biologic therapies, barriers to care with biologic medications, and preferences for biologic therapy attributes.

METHODS

This mixed-methods study involved quantitative surveys and qualitative telephone interviews with patients and physicians from the United States. Participants described preferences for relevant attributes, and barriers to use of biologic medications. Participants rated, ranked, and indicated importance of preferences for different levels of key attributes including: mode of administration, administration setting, dosing frequency, number of injections, and time to onset of effect. Other attributes unique to each group were also included.

RESULTS

A total of 47 patients and 25 physicians participated. Patients ranked out-of-pocket costs, mode of administration, time to onset of efficacy, and administration setting as the most important attributes. Physicians ranked mode of administration, time to onset of efficacy, dosing frequency, and insurance reimbursement/access as most important. Both groups expressed preferences for less frequent administrations (Q8W over Q4W or Q2W) (all P<0.01) and subcutaneous (SC) over intravenous injection (both P<0.0001). Key patient barriers to biologic medications include location of treatment, administration time, scheduling, cost/insurance coverage, number of injections, and mode of administration. Physicians identified patient candidacy, convincing patients, administration setting, mode of administration, cost, and administrative burden as key barriers to initiating therapy; and efficacy, speed of onset, convenience of administration, cost, and patient compliance as barriers to staying on therapy.

CONCLUSIONS

Patients and physicians expressed strong preferences for less frequent dosing, SC administration, and faster onset. Cost/insurance coverage and convenience issues were key barriers to use. Increased awareness and understanding of preferences and barriers may be useful in facilitating physician-patient conversations with the goal of individualizing treatment.

Demography, baseline disease characteristics, and treatment history of psoriasis patients with self-reported psoriatic arthritis enrolled in the PSOLAR registry

Background

To evaluate demographics, family history, and previous medication use at enrollment in a subset of psoriasis patients with self-reported psoriatic arthritis (PsA) enrolled in Psoriasis Longitudinal Assessment and Registry (PSOLAR).

Methods

PSOLAR is an international, prospective, longitudinal, disease-based registry that collects data in patients receiving, or are eligible to receive, systemic or biologic treatments for psoriasis. Baseline demographic, disease characteristics, medical history, and prior medication use at enrollment were evaluated in PSOLAR psoriasis patients self-reporting PsA (n = 4315); a subset of which had their diagnosis of PsA established by a healthcare provider (HCP; n = 1719); patients with psoriasis only (n = 7775); and the overall PSOLAR population (n = 12,090).

Results

At enrollment, demographic characteristics were distinct between psoriasis patients self-reporting PsA and psoriasis only patients. Of the patients with psoriasis self-reporting PsA, 44.4% had cardiovascular disease (CVD), 26.3% had psychiatric illness, and 3.2% had inflammatory bowel disease (IBD), with each more prevalent than among patients with psoriasis only (p < 0.001). Overall, 17.5% of psoriasis patients self-reporting PsA had a family history of PsA, 29.8% had used systemic steroids, 39.5% had used nonsteroidal anti-inflammatory drugs, and 83.5% had used biologics.

Conclusions

Demographics, family history, and previous medication use were generally comparable between “PsA established by a HCP” patients and psoriasis patients self-reporting PsA in the PSOLAR registry, but there were statistical differences compared with the psoriasis only group regarding the prevalence of certain comorbidities (CVD, psychiatric illness, and IBD). These analyses provide important data regarding characteristics of psoriasis patients with self-reported PsA in PSOLAR.

Trial registration

NCT00508547.

Electronic supplementary material

The online version of this article (10.1186/s41927-018-0034-7) contains supplementary material, which is available to authorized users.

Treatment preferences for biologicals in psoriasis: experienced patients appreciate sustainability

BACKGROUND AND OBJECTIVES

Treatment satisfaction can be improved by integrating patients' preferences into shared decision-making. We recently investigated patients' preferences for attributes of biologicals, and showed high preferences for safety and efficacy. The objective of the present study was to assess the impact of treatment experience on these preferences.

PATIENTS AND METHODS

Preferences for outcome (probability of 50 % and 90 % improvement, time until response, sustainability of success, probability of mild and severe adverse events, probability of ACR 20 response) and process attributes (treatment location, frequency, duration, and delivery method) were analyzed in 200 participants with moderate-to-severe psoriasis using conjoint analysis. The impact of current and previous therapies, disease duration, and treatment satisfaction on 'Relative Importance Scores' was determined by analysis of variance, post hoc tests, and multivariate regression.

RESULTS

Participants presently on topical therapy (p = 0.02) or phototherapy (p = 0.032) placed more importance on treatment duration than others. Individuals who had previously been given traditional systemic agents (p = 0.028) or biologicals (p = 0.044) favored sustainability more than others. With an increasing number of systemic agents ever received (p = 0.045) and longer disease duration (p = 0.018), the latter attribute became increasingly important.

CONCLUSIONS

Patients' preferences for biologicals vary in correlation with treatment experience and disease duration, aspects to be addressed in the context of shared decision-making.

The role of IL-23 and the IL-23/TH 17 immune axis in the pathogenesis and treatment of psoriasis

Psoriasis is a chronic, immune-mediated disease affecting more than 100 million people worldwide and up to 2.2% of the UK population. The aetiology of psoriasis is thought to originate from an interplay of genetic, environmental, infectious and lifestyle factors. The manner in which genetic and environmental factors interact to contribute to the molecular disease mechanisms has remained elusive. However, the interleukin 23 (IL-23)/T-helper 17 (TH 17) immune axis has been identified as a major immune pathway in psoriasis disease pathogenesis. Central to this pathway is the cytokine IL-23, a heterodimer composed of a p40 subunit also found in IL-12 and a p19 subunit exclusive to IL-23. IL-23 is important for maintaining TH 17 responses, and levels of IL-23 are elevated in psoriatic skin compared with non-lesional skin. A number of agents that specifically inhibit IL-23p19 are currently in development for the treatment of moderate-to-severe plaque psoriasis, with recent clinical trials demonstrating efficacy with a good safety and tolerability profile. These data support the role of this cytokine in the pathogenesis of psoriasis. A better understanding of the IL-23/TH 17 immune axis is vital and will promote the development of additional targets for psoriasis and other inflammatory diseases that share similar genetic aetiology and pathogenetic pathways.