HS-hoidon onnistumisen määrittely, biologinen valinta ja komorbiditeen tutkimus: Sohvalla Dr. Jennifer Hsiao

In a conversation published on HCPLive, Jennifer L. Hsiao, MD, Professor of Dermatology at the University of California, East and co-director of a HS specialty clinic, answered questions about defining treatment success, making choices among biologics, and where oral JAK inhibition might fit in. Hsiao addressed these topics in two presentations, including one with Iltefat Hamzavi, MD. In the following conversation, Hsiao discussed defining treatment success, making choices among biologics, and where oral JAK inhibition might fit in with the HCPLive team at the conference in Las Vegas.

I tell my patients this: I want you to report less leakage and less pain on your next visit. If you have new lesions, I hope the number is less, they are smaller, and they go away faster. This really shows a decreased frequency of flares, as well as decreased flare severity and duration.

Because when patients come in, you can evaluate and tell me, ‘Yes, I had a few new lesions, but they were smaller and went away faster, so maybe the medication is working for me.’ Or ‘I don’t think this medication is working at all because I’m still getting new lesions.’ So setting treatment expectations is really important for treatment adherence.

Biological Choice: Which One to Start With, When to Switch?

HCPLive: How do you decide which of the approved biologics to start with and when to switch?

Jennifer Hsiao, MD: “We are really fortunate to have three FDA-approved therapies. We have adalimumab, a TNF-α inhibitor; secukinumab, an IL-17A inhibitor; and our IL-17A/IL-17F inhibitor, bimekizumab. At this point, adalimumab and secukinumab are approved for patients 12 years and older, so that helps with our treatment choices in terms of age range.

At this stage, I really think about the patient’s preferences. A patient may come in and say, ‘I heard this about this medication. I definitely don’t want to start on it.’ It’s also important to take into account what patients have heard; because if you have options and someone is adamantly against one for a particular reason, you may not be able to push it on that visit. Patient comorbidities also play a role, and ultimately, access plays a role as well.

HCPLive: If a patient is willing to try a medication, I really want to get that medication into their hands as quickly as possible. With delays, patients may say, “You know, there’s more than enough difficulty with this,” and you may miss a window of time when they’re open to starting therapy. Insurance formulas often come into play here, and I think strong bridges and patient assistance programs can be helpful. But ultimately, our goal is to identify the patient during that window of opportunity, hopefully in early moderate disease, to start them with one of the three therapies we have available and help them start to mitigate disease progression or at least feel better at this point.

When considering JAK inhibitors, the first thing I’m happy about is that we’ll have an oral option. There are still some patients who are afraid of injections, so it’s great to be able to offer a different route of administration. Then there are the patients I mentioned; perhaps the pathophysiology of HS is not dominated by one cytokine and is more heterogeneous. By inhibiting a pathway such as the JAK-STAT signaling, it may be beneficial for these patients to affect a greater number of cytokines.

So definitely, we need more treatments in our toolbox, and it’s exciting to have drugs on the horizon. I think JAK inhibitors are probably the most advanced; povorcitinib is an JAK1-selective inhibitor that recently published a paper with efficacy and safety data up to 54 weeks. It would be really exciting to have access to these drugs once they are approved.

Which Comorbidities Should Be Screened?

HCPLive: Which comorbidities should be screened in patients with HS, and what is a realistic workflow?

Jennifer Hsiao, MD: “The first thing I need to say is that we don’t have to do everything at the first visit. The first visit can be intimidating. The patient has to share their story with you, and at the same time, you as a clinician are trying to understand where the patient came from and what stage they are at, and you’re putting together a treatment plan. This comorbidity screening can probably happen during your physical exam as well.

For cutaneous comorbidities, look for signs of acne and check the scalp. Is there dissecting cellulitis in the scalp? You’ll probably also want to check the groin and buttocks areas; these are areas that are commonly affected by HS, so are there any pilonidal cysts? You can address these cutaneous comorbidities during your physical exam. You can also ask questions about them: Do you have lesions on your scalp? Do you have lesions on your buttocks?

For other comorbidities, you can hire a primary care provider who can help with most of them. On the dermatology side, I believe that one is a tobacco smoker and can recognize this; but at the first visit, it should not be brought up as “You should quit smoking.” It can be brought up at a later visit after establishing a relationship with the patient and clearly stating that you are doing this from a general health perspective. Not because you are not interested in smoking, but because you do not believe that smoking causes HS or that they are in any way to blame for HS. Doing this is really important.