Managed Care - January 2009 - (Page CB-A3)

FIGURE 2 Distribution of psoriasis therapies by disease severity* In six National Psoriasis Foundation surveys from 2003 to 2005, more than one third of patients who reported their disease as being moderate or severe said they had received no treatment. The majority of those who received treatment were given topical therapies. In this survey, moderate disease corresponded to 3–10% of involved body surface area; severe, >10%. Moderate n=683 37% 46% 4% 7% 5% No treatment 39% Topical 34% Phototherapy Traditional Biologic systemic 4% 14% 9% n=459 Severe *If patients received combination therapy, those who received biologic therapy and some other therapy were assigned to the biologic group; those who received traditional systemic agents and either phototherapy or topical agents were assigned to the traditional systemic group; and those who received phototherapy and topical agents were assigned to the phototherapy group. Patients assigned to the topical group received one or more topical therapies but no other form of therapy. Because percentages are rounded to the nearest whole number, these figures may not add up to 100 percent. Source: Adapted from Horn 2007a. Levels of treatment satisfaction An analysis of six NPF surveys suggested that many people with moderate or severe psoriasis are undertreated (Figure 2). The majority of the 1,657 randomly selected respondents with moderate or severe disease reported having received no therapy or topical therapy (Horn 2007a). The most recent guidelines from the American Academy of Dermatology recommend phototherapy, traditional systemic therapy, or biologic agents for patients with extensive disease (Menter 2008). Among patients receiving treatment for severe psoriasis, one study found that nearly 50 percent were only somewhat or not at all satisfied with their therapies, and 32 percent did not believe that their treatment was aggressive enough (Krueger 2001). These findings may indicate the existence of significant dissatisfaction with the ability of treatments to control many symptoms of psoriasis (Krueger 2001). That patients with moderate or severe psoriasis are undertreated also is borne out by a survey of U.S. dermatologists, who indicated that topical therapy (as monotherapy or in combination with other topical agents) was the only therapy prescribed to 47 percent of patients with moderate disease (defined as affected body surface area [BSA] between 3 and 10 percent) and to 37 percent of patients with severe psoriasis (defined as affected BSA more than 10 percent) (Patel 2008). In addition, dermatologists overestimated the rate at which they prescribed biologics to patients with severe psoriasis. They reported that biologics were provided to 41 percent of these patients, but a review of patient records showed that biologics were prescribed for 27 percent of patients with affected BSA between 11 and 20 percent, 34 percent with affected BSA between 21 and 40 percent, and 36 percent with affected BSA greater than 40 percent (Patel 2008). Numerous reasons have been advanced for this undertreatment, including the failure of people with psoriasis to seek medical care (Horn 2007a). Furthermore, the toxic effects of some systemic therapies often caused patients with severe psoriasis to undergo a rotation of therapies (e.g., psoralen and ultraviolet light A, then methotrexate), with the switch to an alternative regimen implemented before evidence of toxicity emerged (Greaves 1995). Co-morbid conditions Individuals with psoriasis are subject to numerous comorbid conditions. However, the association between the disease and these comorbidities is unclear. Psoriasis patients appear to be at an elevated risk for such conditions as obesity (Herron 2005), myocardial infarction (Gelfand 2006a), and lymphomas (Gelfand 2006b). Patients who required hospitalization as a result of their severe psoriasis may face a higher risk of mortality from cardiovascular causes (Mallbris 2004). Patients also face a greater risk of depression — 54 percent of patients with severe psoriasis between the ages of 18 and 34 who participated in an NPF survey reported feeling depressed (Krueger 2001). It has been suggested that psoriasis is the cutaneous manifestation of an underlying systemic disease process that also can be expressed at other body sites afflicted by chronic inflammation (Kourosh 2008). Investigators have observed that the same set of cytokines that characterize psoriatic plaque is found in atherosclerotic plaque and arthritic joints, which may help to explain why patients with psoriasis (and rheumatoid arthritis) are at increased risk of cardiovascular mortality. In a Swedish study, patients with disease severe enough to warrant inpatient 3

Table of Contents Feed for the Digital Edition of Managed Care - January 2009

Managed Care - January 2009 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor Health Care's Disruptive Innovations Q&A With Clayton Christensen 'Disruption' May Be Plans' Best Bet Avoid the PBM Rebate Trap HealthPartners Puts Diabetes on Notice Formulary Files Plan Watch Tomorrow's Medicine Ad Index Outlook Unmet Needs in the Management of Plaque Psoriasis Impact of RSV: Implications for Managed Care

Managed Care - January 2009

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