Definering av framgång i HS-behandling, biologisk val och tarmundersökning: En samtal med Dr. Jennifer Hsiao

In a conversation published on HCPLive, University of California East Dermatology Professor and co-director of a HS specialty clinic Jennifer L. Hsiao, MD, 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 treatment expectations, defining success, making choices among biologics, and where oral JAK inhibition might fit in with the HCPLive team at the conference in Las Vegas.

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 aged 12 and older, which 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 the patients have heard; because if you have options and someone is strongly against one for a particular reason, you may not be able to push it during that visit. The patient’s comorbidities also play a role, and ultimately, access plays a role as well.

HCPLive: If a patient is motivated to be treated, 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 the moment.

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 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 signal, 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 furthest along; 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 does a realistic workflow look like?

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’re 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 acne symptoms and check the scalp. Is there dissecting cellulitis in the scalp? You’ll probably want to check the groin and buttocks as well; 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 in your scalp? Do you have lesions in 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 be aware of that; but on the first visit, it should not be brought up that they should quit smoking. It can be brought up at a later visit, after establishing a relationship with the patient, and you clearly state 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 their HS, or because they are somehow guilty of HS. Doing this is really important.