Evidence and expertise needed to translate psoriasis guidelines into practice


Alan Menter, MD: ‘Most of our guidelines are evidence-based.’

Strong clinical evidence and up-to-date guidelines do not automatically translate into good clinical practice. It takes expert guidance and advice to apply guidelines in the clinical setting and improve patient outcomes.

“We assembled a panel of experts who have spent a lot of time looking at the evidence in psoriasis from a practical perspective to build guidelines that will help our colleagues in clinical practice choose the right therapy for the right patient,” said Alan Menter, MD, long-time chair of AAD’s Psoriasis Guidelines Committee and director of a March 23 Annual Meeting session, “Translating Evidence into Practice: Psoriasis Guidelines.”

“You should not just choose the right therapy, but introduce it in a way that is going to maximize benefits from both the therapeutic perspective and the safety perspective,” said Dr. Menter, chief of dermatology at Baylor University Medical Center and clinical professor of dermatology at the University of Texas Southwestern Medical School, Dallas.

The three-hour session was not just a recitation of AAD’s most recent update to its psoriasis practice guidelines. Presenters added significant new information and practical developments that will be incorporated in the next set of revisions.

Dr. Menter opened the session with a look at biosimilars, which are follow-on versions of familiar biologic agents that have transformed dermatologic care. Biosimilars are to biologic agents what generics are to brand name pharmaceutical agents

“Biosimilars have not even reached the U.S. market,” he said. “The first two biosimilars were approved by the European Medicines Agency and will be coming to the United States along with many other agents. Some of our major drugs are coming off patent over the next two years. We need to start considering how we are going to deal with biosimilars, especially recognizing that biologic therapies are quite expensive compared to methotrexate and other agents.”

Even an area as familiar as phototherapy may involve nuances that are not always obvious simply from reading guidelines. A patient with less than 5 percent of the skin area affected would be a logical candidate for topical therapy rather than phototherapy. But if that 5 percent happened to include the feet and hands, the outlook and treatment choices are more limited.

“It is appropriate to focus on details such as the parts of the body that are involved, how inflamed the skin is, how thick it is, how scaly it is, and how the patient’s quality of life has been affected,” Dr. Menter said. “Plantar and palmar psoriasis are devastating because they affect people’s ability to walk and to use their hands. The practical impact of the disease can play an important role in treatment decisions.”

Some specialty practice guidelines are driven entirely by evidence. Dermatology has moved toward evidence-based practice, but expert opinion still plays an important role. The evidence clearly shows that patients on methotrexate need folic acid supplementation because the agent depletes folic acid, he said. What the evidence does not yet show is how much supplementation is needed. The requisite studies have not yet been performed. In an extension of the guidelines, the psoriasis guidelines work group published “Research Gaps in Psoriasis: Opportunities for Future Studies” in the January issue of JAAD in which gaps in research and care were identified and studies to address these deficits were suggested.

“Most of our guidelines — 90 percent — are evidence-based,” Dr. Menter said. “But no one knows what the appropriate level of methotrexate supplementation is — 1 milligram per day, 2 milligrams, or 5 milligrams? This is one area that remains expert-based, not evidence-based.”

Psoriasis remains a rapidly evolving area with new guidelines issued every two to three years. The 2014 update included a look at new developments in psoriatic arthritis, topical therapy for psoriasis, phototherapy, systemic therapy, biologic therapy, and the current state of knowledge surrounding psoriasis comorbidities and prevention of risk factors.

“We looked at safety issues, dosing issues, new agents, side effects, costs, all of the things that in daily practice absolutely must be taken into consideration,” Dr. Menter said of the 2014 update. “We now recognize that psoriasis, like lupus, is a spectrum with multiple comorbidities. It is time to make psoriatic joint disease an important part of psoriasis, recognizing that one patient out of three will develop joint disease. Our goal is to elevate psoriasis to a new level of understanding. Psoriasis is an important systemic disease, not just a skin disease.”

Be sure to view the Academy’s Web app based on the AAD’s clinical guidelines of care for psoriasis and psoriatic arthritis.

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