Dr. Richard Thomas and Professor Christopher Griffiths team up in interview style to explain some of the key points of the lecture at the inaugural Stuart Maddin Lecture Series at Dermatology Update 2016.
Professor Christopher Griffiths sees an optimistic vision of the very near future for psoriasis patients–clearance not just for 16 weeks but prolonged long term clearance. Some of the topics discussed include the latest developments in psoriasis research, treatment methodologies, and lifestyle recommendations. Importantly, all of these are discussed in the context of individualized or stratified medicine using a multi-omics approach, similar to the models already used in oncology. This exciting new approach leads the way for treatment recommendations that are tailored specifically for the individual–the drug, as well as dosing with the understanding that every individual is different in how they react to or metabolize drugs. Big changes are coming not only in psoriasis or dermatology specifically, but in a greater context of how medicine is practiced in the future.
Q1: In what direction do you think psoriasis treatment is headed in the near future?
I guess there’s two things. One is that psoriasis is a disease that has lent itself very well to a translational approach. So, understanding the pathomechanisms of psoriasis, identifying key cytokine pathways, particularly interleukin-17 and interleukin-23 have allowed us to develop molecules which can target those cytokines to improve the quality of life of our patients, and I think with Anti-R-17 and Anti-R-23 approaches which will come into the market in about a year’s time. We will be able to say for the first time to our patients, “we can promise you almost complete clearance of your psoriasis.” I don’t think that we’ve ever been able to do that before. Not just clearance over just 16 weeks, but over the long-term, because it’s obviously the long-term treatment that we are looking for.
Q2: What do you say to those concerned about the high cost of psoriasis treatments?
Well, it’s a good question. These are expensive treatments, and psoriasis doesn’t kill many people directly. I’d counter that by saying, “well, psoriasis is life-ruining.” It occurs for the first time, usually in the teenage years. An individual’s life is forever changed because of that disease. By that I mean, we know that there is a significant cost to society when an individual has psoriasis. In the U.K. 26 days a year are lost from work due to psoriasis. It costs the U.K. over a billion pounds a year from presenteeism and sickness absence. These are big numbers, and even if they are at work, it’s less productive, and a lot of them are actually getting gainful employment, a lot of them are not getting to the level of education that they would have got to otherwise. There’s a whole series of reasons around this.
So if you can manage psoriasis, effectively, early on, and maybe prevent some of the changes which may lead to psoriatic arthritis, or maybe prevent the development of cardiovascular disease or diabetes or stroke. Then, you can make them a very productive–this is an argument from just pure numbers–member of society and that investment is worth it.
Q3: Individual or tailored treatments is a big topic in medicine. What are your thoughts?
So what you’re talking about here is stratified medicine or personalized medicine. Medicine, you know as well as I do, is not a one size fits all agenda. All of us, as patients want our doctors to provide us the best treatment [specifically] for us, and our psoriasis. Now that may sound far fetched, but in the world of oncology, all oncology drugs, Septin being a good example, come with what’s known as a companion diagnostic–so with some biological testing, you could say that with this patient, they will respond best to this drug. So stratified medicine can use clinical, genetic, immune information on that individual, maybe from a blood test, maybe from a very small 2mm punch biopsy. This will allow you to say to the patient as a dermatologist, you have this sort of psoriasis–because it’s not one disease, it’s several diseases–for this particular psoriasis, you will do the best with this particular drug. So that’s the very first–I think that are going to be able to do that. We can only do that now because we can combine all sorts of information, called the multiomics platform–proteomics, immunology, genomics, phenomics, which is the sort of phenotype of the patient. We pull all that information together to get a sort of Star Trek sort of scenario. Ok you have this sort of psoriasis, you are going to do best on this–Methotrexate, even, but it’s not just the drug. It’s also the lifestyle management that goes with that, and that’s very important. So it’s understanding that they might be depressed, it’s understanding that if they lose weight, that will improve their response to a drug or may even improve psoriasis by itself, stopping drinking and stopping smoking will improve psoriasis. Exercise and diet, all of those things will make a difference, but together, with all of these modern drugs, we have a phenomenal opportunity to clear patients of psoriasis, and improve their quality of life.
Q4: Do you think that this will be achievable in the near future?
Yeah, I do think that it’s achievable. I think that the lifestyle management is achievable, using motivational interviewing and other techniques, and also as I mentioned earlier, with the multiomics platform, the ability to integrate that data and analyze it using what’s called machine learning, which will give us an algorithmic approach allowing us to give the right treatment for them, whatever that might be, the first time. It’s definitely going to happen.
Q5: Can you tell us a bit more about motivational interviewing?
Motivational interviewing is where, rather than me just telling you to do something–which you’re not going to respond to; oh I’m not going to do that!–is to get the patient and the practitioner on the same side so that you both have the same goals. One of the examples that I used at my lectures is weight loss. We do know that obesity itself is a driver for developing psoriasis, but losing weight is a crucial thing. If I just told you to lose weight, you’re going to say, “oh forget it, I don’t have time to do that,” but if I sort of make you think about why it might be important to lose weight, it makes a difference.
If I say, how much would you like to lose weight, if you could give it a score from 0 to 10 where 10 is the most. You might say, 4. Well I’d counter that by saying, well that’s interesting, why isn’t it less than 4? You’ll say, well I’ve heard that reducing my weight reduces my chances of getting diabetes, or getting arthritis and perhaps I should be doing something about that. So immediately, the balance has shifted, and the patient is thinking, well there’s things that I could do to help myself. That’s what motivational interviewing is about. It’s the same techniques that are being used to quit smoking or stop consumption of alcohol.
Q6: It sounds like the future of medicine will be about individualizing medicine?
Yes, exactly. It’s got to be an individual; we’re all individuals and that’s the point. You can’t just put it all into the same package. That’s with dosing for biologics as well. At the moment, as you know, it tends to be fixed dosing–this is the dose, this is the frequency. That might be true of the general group, but actually, for the individual you might have double the dose, you might need to have the treatment every 4 weeks instead of every 2 weeks. Once a week instead of two weeks. So it’s tailored to you, and your needs as everyone metabolizes these drugs differently. I think the key thing is that psoriasis isn’t a single disease; it’s several.