George Han, MD, PhD: Navigating the Crowded Field of Biologics for Patients With Psoriatic Disease

The biologic landscape for treating psoriatic disease is expanding rapidly, with more than 10 approved agents and several biosimilars currently available, and many more in development. This ever-increasing number of treatment options can make it challenging for clinicians to identify the most suitable biologic for individual patients with psoriasis.

In an upcoming session at the American Academy of Dermatology (AAD) 2023 Annual Meeting, held March 17-21, in New Orleans, Louisiana, a panel of physicians will explore the factors to consider when weighing treatment options, such as the presence of comorbidities, previous treatments, patient preferences, and more.

Ahead of the discussion, session director George Han, MD, PhD, associate professor at the Zucker School of Medicine at Hofstra Northwell in New York, spoke with Dermatology Times® and encouraged colleagues to attend this case-based forum that will offer insights relevant to real-world clinical practice.

This transcript has been edited for clarity and length.

Dermatology Times: You will be directing a session at AAD on “So Many Biologics, So Little Time: How to Pick Your Poison in an Era of Biologic Overload.” Why should your colleagues attend this session?

Han: I'm really glad that the AAD picked up our session a couple of years ago. We actually had our first session the year before COVID hit and we [were] kind of excited by how many people are interested in this subject. Even though it seems like we're inundated—I was driving the car this morning hearing psoriasis commercials, watching TV, [you] see it all the time—there is a lot out there on psoriasis, but still we have a lot of patients coming in who need our help.

What happens is that you sit there and it's kind of overwhelming, right? There are 11 biologics now—[with] more coming—approved for plaque psoriasis, and you have to think about psoriatic arthritis, you have to think about all the comorbidities. We're getting more and more data dealing with special sites, looking at special patient considerations, and it's almost like we've gotten to the point where we have good biologics, we have good medicines that work well on our patients. Now we're in an era where we can actually start to dissect out what aspects of the patient history do we really focus on to really pick the right and precise medicine for them, and we're really entering a new era for that. So that was the thought behind this forum.

I'm really glad this year that we've got an all-star lineup. We've got April Armstrong, Kristina Callis-Duffin, Bruce Strober, Sylvia Hsu, Ken Gordon. These are kind of like my personal heroes in the dermatology and psoriasis space and I'm just so excited. They'll be talking to us about a lot of different topics. We're trying to make it really practical [and] case-based. We'll be figuring out [for when] that patient comes in with the certain comorbidities, what are we really going to ask? What are the right questions? How do we do it efficiently? How do we really think about psoriatic arthritis? What screening questions or tools do we use? And really just a lot of great cases and examples of how we're going to go about selecting the right medicines for our patients.

Dermatology Times: As a physician, what sort of process is happening in your mind as you weigh which biologic to select for a patient with psoriatic disease? What factors are you considering?

Han: I think it's interesting because we have 3 general classes of medicines. Honestly, you pick any of those medicines [and] the patient is going to get marked improvement; they're going to be much happier. But we're almost at a point where we're thinking, “How much happier could we make them?” You think about these [National Psoriasis Foundation] NPF treat-to-target guidelines…we're thinking about getting the patient down to 1% [body surface area affected]. You might say it's an aggressive goal, but it's really a realistic goal based on where we're at right now with our medicine. Even though a patient who was on an older generation medication might have gotten 60 or 70% clear and they're happier than they were when they had psoriasis all over…how much happier could we make them? How much better can we make them? How much could we improve their quality of life? These are things we think about with perhaps switching therapies, and so those are the some of the harder subjects that we'll delve into…really thinking about those challenging patients who have tried and failed multiple medications in the past.

What about that patient where the skin is doing well but their joints are flaring? What do we do with that patient? Do we switch them? Do we add on additional treatments? I have patients who have failed several biologics and we think about 3, 4, 5, 6...I've had patients who've tried 8 biologics in the past. What do we do with those patients? What about the patients who have maybe that family history of [irritable bowel disease]? Who have cardiovascular comorbidities? How do we start to think about implementing that? And what about the psychiatric comorbidities as well, right? We know psoriasis really affects our patients deeply. When it was studied, we looked at how much these major medical conditions affected people and [psoriasis] was right up there with cancer. Psoriasis is really powerful in that it affects so many domains of our patients’ lives and, often, the challenge really is in our busy day-to-day practice, how do we whittle down that conversation and really answer all the questions we need to in an efficient amount of time?

Dermatology Times: What does the future of biologics look like for these disease states? Are there any agents in the pipeline that you are particularly excited about?

Han: The future pipeline is exciting because even though we have so many medicines, we're still trying to innovate and get better, not only in the biologic realm, but also in oral medicines, in topicals. There's so much going on in psoriasis now. We've gotten solutions to things we didn't know we had problems with but now we have them in our hands and we're like, “This really is very helpful for my practice.” The patients coming in asking for even oral medicines so part of this is, actually, when is it appropriate to not use a biologic? Patients asking for oral medicines, we have new treatments and new ones on the horizon. We're excited about some of these medicines that work on their microbiome. We're excited about some of these medicines that are novel pathways. TYK2 [tyrosine kinase 2] and already we have 1 agent for that, but more in the pipeline. A lot of data releases that are coming at AAD that we're excited about seeing as well.

Then, in the biologic realm, of course, we're starting to hear about different types of IL-17 inhibitors. Whereas we've had IL-17A inhibition, we've had receptor inhibition, now we're starting to talk about different forms of IL-17, IL-17A and F…Bimekizumab, for example, can get you maybe a little better clearance in terms of skin and joints, and we're starting to see the highest rates of PASI [Psoriasis Area and Severity Index] 100 clearance we've ever seen. [In] some of these studies, we're getting up to 70% PASI 100 clearance. This is just a great time to be able to offer these medicines to our patients, but really kind of guiding them through that conversation. What's an appropriate starting point? What are the risks and benefits? How do we continue monitoring these patients, especially if they are on multiple therapies [or] have tried different things…[It] becomes a little overwhelming at times. We're going to try to dissect that down in a practical format to really give people an idea of how to approach these questions.

The AAD session, “So Many Biologics, So Little Time: How to Pick Your Poison in an Era of Biologic Overload,” will be held Friday, March 17, 2023, from 3:30-5:30 PM CDT in New Orleans Theater A.

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