HS治疗中的成功定义、生物选择和并发症检测：与Jennifer Hsiao博士的对话

In the interview 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 how to define treatment success, make 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 interview, Hsiao discussed treatment expectations, how to define success, and where oral JAK inhibitors 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 years 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 about this drug. I definitely don’t want to start on it.” It’s also important to consider what the patients have heard; if they have a specific reason to be strongly against one of the options, you may not want to push it during that visit. The patient’s comorbidities also play a role, and ultimately, access plays a role as well.

If a patient is willing to try a medication, I really want to get that medication into the patient’s 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, 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.

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: “Medications aren’t like an antibiotic that you take for a week and clear up an infection. We emphasize in HS that there’s so much 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 continue on 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 don’t want to be deprived of a treatment that might ultimately provide 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 inhibitors 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 therapies that demonstrate that are welcome. Part of that is because HS is heterogeneous in terms of pathophysiology. Patients may have inflammation associated with different cytokines; some are good IL-17 responders but not TNF responders, or vice versa, and others don’t respond adequately to either.

When considering JAK inhibitors, the first thing I am happy about is that we will have an oral option. There are still some patients who are afraid of injections, so it would be 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 is 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: 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 try to understand where the patient came from and what stage they are at, and you create 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 should probably also check the groin and buttocks regions; 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 be aware of that; but on 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, or because you do not believe that smoking causes HS, or because they are somehow guilty of HS. Doing this is really important.