Conclusions from 'Strategy to manage the treatment of severe psoriasis: considerations of efficacy, safety and cost'

Steven R Feldman, Rachel Garton, William Averett, Rajesh Balkrishnan & Jeffrey Vallee: Departments of Dermatology, Pathology and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1071, USA

Psoriasis is a common condition that has significant pharmacoeconomic implications. Treatment with toxic or expensive medications is often justified by the tremendous impact this disease has on patients’ quality of life. The development of new biological therapies adds considerably to the array of options available to treat patients. While wonderfully effective and relatively free of collateral organ toxicities, they are considerably more costly compared to other established treatments. These developments will bring pharmacoeconomic considerations of psoriasis treatment to the forefront.

Expert opinion: First-line treatment for severe psoriasis

The use of UVB phototherapy is one of the least costly treatments in terms of achieving treatment success and perhaps the safest way to manage psoriasis. Unfortunately, it is inconvenient. Given the cost and risks of alternative therapies, disincentives to the use of office UVB phototherapy are not logical. Fair reimbursement for the UVB procedure (at or above current Medicare reimbursement levels) and elimination of patient copays would encourage the use of this approach, improving patient safety and reducing insurers’ exposure to high cost biological therapies. Moreover, home UVB phototherapy should be promoted for appropriate patients who require long-term UVB as a maintenance therapy for their disease because this would eliminate most of the major inconveniences of phototherapy: frequent travel to the office for sessions, co-payments for each treatment and lost time from work.

With its safety and efficacy, Goeckerman day treatment programmes should also be encouraged as a first-line treatment option for patients with severe psoriasis who would not be expected to respond to UVB phototherapy alone. Encouraging its use (i.e., providing appropriate reimbursement and eliminating copays at each visit) would reduce the need for riskier systemic therapies and for more costly biological treatments.

For patients who either do not respond or are not expected to respond to UVB alone, the combination of UVB plus an oral retinoid provides greater efficacy while maintaining an excellent long-term safety profile. Phototherapy does not treat psoriatic arthritis, so when significant arthritis is present, systemic therapy will be needed.

Second-line treatment for severe psoriasis

Beyond the use of UVB, choosing the next step in psoriasis management is complicated. Methotrexate offers a good efficacy: cost ratio; however, short-term risks (haematological toxicity) and long-term risks (hepatotoxicity) raise serious doubts concerning its place as the second-line treatment for psoriasis. PUVA is still a good consideration, with an excellent efficacy: cost ratio but long-term risk of cutaneous malignancy (including melanoma) makes its use as a standard second-line agent less attractive.

From the standpoint of safety and efficacy, new biologicals appear to be an excellent choice for patients who fail or are not candidates for UVB phototherapy. The safety of alefacept and the efficacy and good safety profile of TNF inhibitors make these drugs promising as second-line agents from a risk:benefit ratio standpoint. The higher cost of these theraStrategy to manage the treatment of severe psoriasis: considerations of efficacy, safety and cost 8 Expert Opin. Pharmacother. (2003) 4(9) pies, however, limits enthusiasm for a high position on the therapeutic ladder.

In short, PUVA, methotrexate, alefacept and etanercept (and probably infliximab and other TNF inhibitors) all appear to be appropriate second-line choices for psoriasis, each with advantages and disadvantages. Considerable patient and physician judgement is required in deciding which of these agents to prescribe in which order. Ideally, the cost-effectiveness of therapies would be an important component of this decision process. However, within a healthcare delivery system in which payment is made by a third-party, patients and physicians may have little or no incentive to consider the cost of therapy. Developing an acceptable approach to encouraging such consideration is problematic. The cost of biological therapy is so great that even a 10 – 20% copay for such a therapy might put the therapy out of reach of patients who need it for control of their disease.

Different structures of healthcare financing provide very different incentives for choice of therapies. Patients who have first dollar coverage for drug costs may be inclined to choose etanercept over other options, including phototherapy. Patients without prescription drug coverage have an incentive to choose physician-delivered treatments, such as alefacept, that would likely fall under their medical benefit.

Third-line treatment for severe psoriasis

The long-term risk of nephrotoxicity in cyclosporin therapy precludes recommending it for the long-term management of psoriasis above other, less toxic alternatives. Its higher cost compared to other, non-biological psoriasis therapies also limits enthusiasm for its use. However, it is still an appropriate therapy for short-term treatment of a disease flare, for reducing disease severity before transitioning to a safer long-term treatment or for patients not adequately controlled with other treatments. Hydroxyurea because of its very narrow therapeutic window, is another third-line agent for the management of severe psoriasis.

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