HS治療における成功の定義、生物学的選択、および併存疾患のスクリーニング：Jennifer Hsiao医師との対談

In a conversation published on HCPLive, Jennifer L. Hsiao, MD, a professor of dermatology at the University of California, East Dermatology, and co-director of a HS specialty clinic, addressed questions about defining treatment success, making choices among biologics, and where oral JAK inhibitors might fit in. Hsiao also 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 inhibitors might fit in with the HCPLive team at the [conference] in Las Vegas.

I tell my patients this: I want you to report less flare 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. That really shows a decreased frequency of flare, decreased severity of flare, and decreased duration of flare.

Because when patients come in, I can evaluate them and say, ‘Yes, I had a few new lesions, but they were smaller and went away faster, so the medication may be 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 bimekizumab, an IL-17A/IL-17F inhibitor. 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 drug. 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 has a strong objection to one of them, you may not want to push it on that visit. Patient comorbidities also play a role, and ultimately, access plays a role.

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 in 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, 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.

How Long Should Treatment Last?

HCPLive: How long do you give a patient before deciding that a therapy isn’t working, and how do you discuss that timeline with patients?

Jennifer Hsiao, MD: “The medications we’re talking about here aren’t like an antibiotic, where you take one for a week and it kills the infection. We emphasize in HS that there’s a lot of inflammation that we really need to get under control. So I see a timeframe of 3 to 4 months for a re-evaluation, and you have to set that up from the beginning. That way, patients can stick with the therapy even if it takes a little longer.

We have a limited number of therapies, and patients understand the concept of not wanting to exhaust the treatment options we have. You may not want to be deprived of a treatment that might eventually give you a good response, but you just didn’t have the stamina to keep going.

What Are Oral JAK Inhibitors?

HCPLive: Where do you place oral JAK inhibition in the HS treatment landscape?

Jennifer Hsiao, MD: “Right now, we’ll take anything that has good efficacy and safety and gets FDA approval. All the therapies that demonstrate that are welcome. Part of that is because HS is heterogeneous in terms of pathophysiology. There may be patients whose inflammation is associated with different cytokines; some are good IL-17 responders but not TNF responders, or vice versa, and others who don’t respond well to either.

When thinking about 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 nice to be able to offer a different delivery method. Then there are the patients I mentioned; perhaps the pathophysiology of HS is not dominated by one cytokine and is more heterogeneous. Inhibiting a pathway such as the JAK-STAT signal transduction may be beneficial for these patients by affecting 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 furthest along; povorcitinib is a 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: In patients with HS, which comorbidities should be screened, and what is a realistic workflow?

Jennifer Hsiao, MD: “The first thing I need to say is that we don’t need to do everything at the first visit. The first visit can be intimidating. The patient needs 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’re at, and you’re putting together a treatment plan. This comorbidity screening may also happen during your physical examination.

For cutaneous comorbidities, look for acne symptoms and check the scalp. Is there dissecting cellulitis on 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 examination. 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 of my patients is a tobacco smoker, and I can recognize that; but they should not be told to quit smoking at the first visit. 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, or because you do not believe that smoking causes HS or that they are somehow to blame for HS. Doing this is really important.