What the NPF/Canadian guidelines offer physicians is a rigorous evaluation of the literature with a patient-focused approach to psoriasis treatment, said Dr. Kim A. Papp, director of research at Probity Medical Research, Waterloo, Ont., who helped coauthor both sets of guidelines.
"We all appreciate that the art of medicine incorporates habit, consensus, experience, and hopefully sound data," he said. "Consequently, a second and perhaps equally important offering of the guidelines to physicians is an independent affirmation or an independent negation of one’s art in treating psoriasis."
Where the NPF guidelines may prove particularly helpful is in supporting that therapeutic choice with insurers. If a physician thought that a particular biologic agent was the best treatment option for a patient, that physician could point to the guidelines as a way to let insurers know that what is being recommended is within the standard of care, said Dr. Feldman.
The new guidelines could also push physicians to be more aggressive in using some of the available systemic agents. He pointed out that one of the "major enthusiasms" for creating the guidelines was a 2009 National Psoriasis Foundation survey finding that 57% of patients with severe psoriasis were receiving treatment insufficient to achieve adequate control (J. Am. Acad. Dermatol. 2007;57:957-62).
©2011 National Psoriasis Foundation
New guidelines for treating plaque psoriasis focus on managing the disease beyond the topical level.
"There needed to be guidelines that would encourage physicians to provide patients treatment that met the severity of their illness," said Dr. Feldman, who suggested that safety concerns, dated training, and a perception that psoriasis isn’t such a bad disease, all played into the lack of aggressive treatment.
The NPF guidelines clearly detail the safety risks associated with each agent, and have a specific section on special populations, including pregnant women, patients with HIV, and those with hepatitis B or C.
For the purpose of the new guidelines, patients are considered to have moderate to severe psoriasis if they cannot achieve or would not be expected to achieve adequate control using topical agents, with adequacy defined by the patient’s own perception of the disease and its burdens. Cutoffs based on clinical metrics, such as the Psoriasis Area and Severity Index, percentage of body surface area affected, and the Dermatological Life Quality Index are necessary in clinical trials, but "have little value in daily practice," the authors noted.
Strict numeric cutoffs can also cause problems with insurers and reimbursement.
"This [document] provides the insurers and other regulators the opportunity to set more meaningful standards for their policies," Dr. Feldman said. "When they see guidelines published in the Archives and supported by the National Psoriasis Foundation, it lends a lot of weight to doing things the way doctors do things in the patient’s best interest."
The physicians interviewed for this story all disclosed consultancies and research arrangements with multiple companies that manufacture psoriasis treatments.