Evaluating Psoriasis: Patient Reported Outcomes and Impact of Disease Bruce E. Strober, MD, PhD Professor and Chair Department of Dermatology University of Connecticut Farmington, Connecticut
DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY Evaluating Psoriasis: Patient Reported Outcomes and Impact of Disease F029 Bruce Strober, MD, PhD Consultant and Advisory Boards AbbVie, Amgen, Astra Zeneca, Celgene, Dermira, Janssen, Leo, Eli Lilly, Cutanea-Maruho, Medac, Novartis, Pfizer, Sun Pharma, Boehringer Ingelheim, UCB Investigator AbbVie, Amgen, Boehringer Ingelheim, Galderma, GlaxoSmithKline, Novartis, Eli Lilly, Janssen, Merck, Sun Pharma, Celgene Scientific Director CORRONA Psoriasis Registry Grant Support to the University of Connecticut for Fellowship Program AbbVie, Janssen
Advances in Research have Resulted in a Decade of Rising Expectations Response goal PASI 50 1 PASI 75 2 PASI 90 3 PASI 100 4 Before Year 2004 2004 2009 2014 and beyond Is going from almost clear to clear MEANINGFUL? 1. Carlin CS; et al. J Am Acad Dermatol. 2004;50:859-866. 2. Leonardi CL; et al. N Engl J Med. 2003;349:2014-2022. 3. Papp KA; et al. Lancet. 2008;371:1675-1684. 4. Leonardi CL; et al. N Engl J Med. 2012;366:1190-1199.
Question to Audience Do you believe that patients consider higher levels of clearance in psoriasis clinically meaningful? 1. Yes; the efficacy of drugs does play the predominant role for patients. Higher levels of clearance are very important. 2. No; patients worry most about side effects related to drugs. Robust efficacy is a secondary concern.
Dermatologists and Patients View Psoriasis Differently 1 Importance rank for dermatologists Importance rank for patients (%) 1 (%) 1 1. Side effects (87%) 1. Efficacy (78%) 2. Cost (80%) 2. Availability (55%) 3. Route of administration (68%) 3. Convenience (52%) 4. Availability (52%) 4. Side effects (52%) 5. Duration of response (38%) 5. Duration of response (50%) 6. Time required for treatment (35%) 6. How fast treatment works (46%) Patient preferences are often elicited but not subsequently used in decision-making 2 A well-informed; shared decision-making process is important for effective disease management 1;2 1. Tan J; et al. J Cutan Med Surg. 2011;15:192-200. 2. Umar N; et al. Acta Derm Venereol. 2012;92:341-346.
Psoriasis Patient Expectations Clearance of psoriasis: the more the better After a patient is cleared; the standards change Worsening disease after initial response is an extremely negative event Patient-reported outcomes (PROs) complement and qualify objective ( observer only ) tools Not all PROs are equal Certain symptoms of psoriasis are universal Not all body areas are equal Gender and age biases are strong
How do we Assess Patients with Psoriasis? Clinical Assessments Psoriasis Area and Severity Index (PASI) 1 Physician s or Investigator s Global Assessment (PGA or IGA) 2;3 Body surface area (BSA) 4 Patient-reported Outcomes Dermatology Life Quality Index (DLQI) 5 Psoriasis-specific PROs Psoriasis Symptom Assessment (PSA) Scale 6 Psoriasis Symptom Diary (PSD) 7 Psoriasis Symptom Inventory (PSI) 8 1. FredrickssonT; et al. Dermatologica. 1978;157:238-244. 2. Langley RG; Ellis CN. J Am Acad Dermatol. 2004;51:563-9. 3. Rich P; et al. Br J Dermatol. 2013;168:402-11. 4. Puzenat E; et al. J Eur Acad Dermatol Venereol. 2010;24S2:10-16. 5. Finlay AY; Khan GK. Clin Exp Dermatol. 1994;19:210-216. 6. Shikiar R; et al. Health Qual Life Outcomes. 2003;1:53. 7. Lebwohl M; et al. Int J Dermatol. 2014;53:714-722. 8. Bushnell DM; et al. J Dermatolog Treat. 2013;24:356-360.
Clinical Assessments Provide Information on the Extent and Severity of Psoriasis Lesions PASI 1 PGA 1 IGA 2 BSA 3 Features Assessed/Measured Presence and severity of redness; thickness; and scaling; weighted by involvement of specific body areas Overall disease severity Percentage of body surface covered with psoriasis lesions Limitations Complex calculation and wide range of score contribute to inter-rater scoring variation Lack of consistency/consensus in scale definition; may not agree well with PASI and BSA Does not assess lesion severity Clinical improvements in these measures do not necessarily translate into patient-perceived benefit 1. Langley RG; Ellis CN. J Am Acad Dermatol. 2004;51:563-569. 2. Rich P; et al. Br J Dermatol. 2013;168:402-411. 3. Puzenat E; et al. J Eur Acad Dermatol Venereol. 2010;24(Suppl 2):10-16.
*All items rated over the preceding week Finlay AY; Khan GK. Clin Exp Dermatol. 1994;19:210-216. DLQI: Widely Used in Clinical Trials Item* Score 1 Symptoms: itchy; sore; painful; or stinging 2 Feelings: embarrassment or self-consciousness due to skin 3 Domestic activities: shopping or looking after home or garden 4 Clothing choice 5 Social or leisure activities 6 Participation in sports 7 Work or study 8 Relationships 9 Sexual interactions 10 Treatment (degree of mess or time necessary) 0 = Not at all 1 = A little 2 = A lot 3 = Very much Items are not psoriasis specific
DLQI Correlates with PASI Decrease Mean reduction in DLQI score 12 10 8 6 4 2 Correlation analysis of mean percent reduction in PASI vs mean reduction in DLQI R 2 = 0.8055 0 25 35 45 55 65 75 85 95 Mattei PL; et al. J Eur Acad Dermatol Venereol. 2014;28:333-337. Mean reduction in PASI (%)
Mean reduction from baseline DLQI at Week 16 Mean improvement in DLQI according to PASI response 1 0 2 4 6 8 10 Increased Skin Clearance Leads to Greater Improvement in Quality of Life PASI < 75 (n = 65) PASI 75 to 89 (n = 15) * PASI 90 to < 100 (n = 29) PASI 100 (n = 32) % of patients with DLQI 0/1 at Week 16 100 80 60 40 20 0 Proportion of patients achieving DLQI 0 or 1 according to PASI response 2 PASI < 75 (n = 63) 1. Edson-Heredia E; et al. IID. 2013. 2. Edson-Heredia E; et al. J Eur Acad Dermatol Venereol. 2016;30:864-5. * * PASI 75 to < 90 (n = 15) PASI 90 to < 100 (n = 29) PASI 100 (n = 32) *P = 0.0015 or lower vs PASI < 75. Other between-group differences P = NS P < 0.05 for pairwise comparison vs PASI < 75 and P < 0.05 for pairwise comparison vs PASI 75 to < 90 NS = not significant
Question to Audience In terms of improvement in QoL; is there a difference between almost clear skin and completely clear skin? 1. No almost clear is adequate and no different from clear. 2. Yes but the difference is insignificant for most patients. 3. Yes the difference is substantial à clear is much better than almost clear.
Almost Double the Number of Patients with Clear Skin Have DLQI 0 than Those with Minimal Psoriasis Patients (%) with DLQI 0 70 60 50 40 30 20 10 CHAMPION and REVEAL Secondary analysis from two phase III studies of adalimumab (combined n = 1469) Percentages of patients with DLQI total score = 0 by physician s global assessment of disease activity at week 16 0 Clear (n = 228) Revicki DA; et al. Dermatol. 2008;216:260-270. Minimal (n = 408) Mild (n = 220) Moderate (n = 333) Severe (n = 167) Physician s global assessment of disease activity
Quality of Life Worsens Out of Proportion to Worsening in the Objective Signs of Disease REVEAL subanalysis: Patients who received adalimumab from baseline and had a PASI 75 response at week 16 and week 33 were rerandomized 1:1 at week 33 to receive blinded therapy with adalimumab 40 mg EOW or placebo EOW from week 33 to week 52. The DLQI and PASI relationship was compared for adalimumab-treated patients while on therapy versus after protocol-mandated treatment discontinuation. Poulin Y; et al. Dermatol Ther. 2014;4:33-42.
Quality of Life Worsens out of Proportion to Worsening in the Objective Signs of Disease N = 1212 Adalimumab n = 814* PASI 75 responders required to continue to Period B Adalimumab n = 580 PASI 75 responders required to continue to Period C Adalimumab n = 250 Placebo n = 240 Placebo n = 398 Adalimumab n = 26 Adalimumab n = 22 0 16 33 52 REVEAL week Poulin Y; et al. Dermatol Ther. 2014;4:33-42. *40 mg EOW from Week 1 after 80 mg at Week 0; 40 mg EOW from Week 17 after 80 mg at Week 16
Quality of Life Worsens out of Proportion to Worsening in the Objective Signs of Disease 100 80 PASI 75 PASI 90 PASI 100 Patients (%) 60 40 20 Poulin Y; et al. Dermatol Ther. 2014;4:33-42. 0 Week 33 n = 240 Week 52 n = 237
Quality of Life Worsens out of Proportion to Worsening in the Objective Signs of Disease At Week 52; mean PASI scores were lower (improved); yet mean DLQI scores were higher (worse) than they had been early in treatment (Week 4). Mean PASI and DLQI scores PASI DLQI Baseline 19.5 11.6 Week 4 8.0 4.3 Week 33 1.2 1.0 Week 52 6.7 5.3 Poulin Y; et al. Dermatol Ther. 2014;4:33-42.
Quality of Life Worsens Out of Proportion to Worsening in the Objective Signs of Disease The same PASI score predicted a higher DLQI score for patients at Week 52 than at Week 4. Mean DLQI score Poulin Y; et al. Dermatol Ther. 2014;4:33-42. Mean PASI score Week 4 Week 52
Quality of Life Worsens Out of Proportion to Worsening in the Objective Signs of Disease Psoriasis patients who are effectively treated may display a reset of what disease level is tolerated. Treatment discontinuation after initial success may result in a rebound dissatisfaction with returning disease. Dose reduction after initial treatment success may result in a similar phenomenon. Poulin Y; et al. Dermatol Ther. 2014;4:33-42.
Skin Symptom Location Can Significantly Affect Quality of Life in Patients with Psoriasis (REVEAL study) Percentage contribution of body region* Aged <45 years Head 40 30 20 10 Aged 45 years Head 40 30 20 10 Upper Trunk Upper Trunk Contribution (%) of body region to total DLQI score (male) Contribution (%) of body region to total DLQI score (female) Kimball AB; et al. AAD. 2012. Lower Contribution (%) of body region to BSA (reference; combined male and female) Lower *All departures from the reference (contribution to BSA) were statistically significant. Skin lesion severity on the head and upper extremities had disproportionately large impacts on DLQI compared with BSA; particularly for younger women and men
Question to Audience Do you feel we need additional assessment tools to help us better understand patient needs? 1. No What we already have is adequate. 2. Yes We cannot fully understand our patients and their needs with what is available.
Psoriasis-Specific PROs May Reflect Patient Status Better than DLQI Dermatology Life Quality Index (DLQI) does not adequately provide coverage for psoriasis-specific symptom measurement The use of a PRO that adequately captures symptoms associated with psoriasis is important in assessing treatment efficacy For example; the Psoriasis Symptom Inventory (PSI) was developed as a psoriasis-specific patient reported eight-item measure of symptom severity and has demonstrated good reliability and validity in patients with psoriasis Bushnell DM; et al. J Dermatol Treat. 2013;24:356-360. Martin ML; et al. J Dermatolog Treat. 2013;24:255-260.
Psoriasis-Specific PROs Should Meet Four Criteria Assess patient experiences most relevant to psoriasis Ask questions about experiences in a manner patients can understand Avoid unreasonable burden on patients recollection of events Easy to complete in approximately five minutes Lebwohl M; et al. Int J Dermatol. 2014;53:714-722.
PROs Provide Information on Patient Perception of Psoriasis Disease factors assessed Recall period Comments Dermatology Life Quality Index (DLQI) 1 Symptoms Psychosocial impact Physical impairment Treatment 1 week Does not assess: Some symptoms relevant to psoriasis Symptom severity Psoriasis Symptom Assessment (PSA) Scale 2 Symptom frequency and burden 2 weeks Does not assess: Clinical severity of symptoms Psychosocial impact Psoriasis Symptom Inventory (PSI) 3 Symptom frequency and severity 1 day or 1 week Does not assess psychosocial impact Instrument has been used in clinical trials Psoriasis Symptom Diary (PSD) 4;5 Symptom frequency; burden; and severity Psychosocial impact Physical impairment 1 day Instrument has been used in clinical trials Longer recall periods and failure to assess symptoms relevant to psoriasis may limit utility of some PROs 1. Finlay AY; Khan GK. Clin Exp Dermatol. 1994;19:210-216. 2. Shikiar R; et al. Health Qual Life Outcomes. 2003;1:53. 3. Bushnell DM; et al. J Dermatolog Treat. 2013;24:356-360. 4. Lebwohl M; et al. Int J Dermatol. 2014;53:714-722. 5. Strober BE; et al. Value Health. 2013;16:1014-1022.
Psoriasis Symptom Diary: Higher Levels of Skin Clearance Can Have a Meaningful Impact on Key Symptoms 100 Probability of response (%) 80 60 40 20 PASI 75 PASI 90 0 Likelihood of a response at week 12 Phase III ERASURE and FIXTURE studies of secukinumab Gottlieb AB; et al. AAD. 2015. PSD itching PSD pain PSD scaling
Psoriasis Symptom Inventory: 8-Item Measure of Psoriasis Symptom Severity 1-2 For the following group of questions; the last 24 hours means from right now - back to yesterday at this time. 1) Overall; during the last 24 hours; how severe was the itch from your psoriasis? 2) Overall; during the last 24 hours; how severe was the redness of your skin lesions? 3) Overall; during the last 24 hours; how severe was the scaling of your skin lesions? 4) Overall; during the last 24 hours; how severe was the burning of your skin lesions? 5) Overall; during the last 24 hours; how severe was the stinging of your skin lesions? 6) Overall; during the last 24 hours; how severe was the cracking of your skin lesions? 7) Overall; during the last 24 hours; how severe was the flaking of your skin lesions? Not at all Mild Moderate Severe Very Severe Symptoms: itch; redness; scaling; burning; stinging; cracking; flaking; pain Each symptom is scored from 0 (not at all severe) to 4 (very severe) Total Score ranges from 0 (best) to 32 (worst) 8) Overall; during the last 24 hours; how severe was the pain of your skin lesions? 1. Bushnell DM; et al. J Dermatol Treat. 2013;24:356-360. 2. Martin ML; et al. J Dermatolog Treat. 2013;24:255-260.
Psoriasis Symptom Inventory: Higher Levels of Skin Clearance Can Have a Meaningful Impact on Key Symptoms Mean total PSI Scores Feldman SR; et al. AAD. 2015. 6 5 4 3 2 1 0 Total Mean Total and Item PSI Scores in Patients with spga 0 vs 1 Mean item PSI Scores 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Itch Redness Scaling Burning Stinging Cracking Faking Pain spga 0, n = 79 spga 1, n= 151 P < 0.001 for total and each item PSI score Patients received ustekinumab; adalimumab; infliximab; or etanercept spga 0 = complete skin clearance; spga 1 = almost clear skin
Summary Patients may view psoriasis differently versus dermatologists Priorities when considering treatment options Expectations of treatment outcomes Higher levels of skin clearance can improve QoL; and may be associated with a meaningful impact on key patient reported symptoms Discontinuation of therapy can have negative effects in patients; including a loss of objective response and a disproportionately large negative impact on HRQoL Obtaining feedback from patients is an important part of clinical practice PROs help patients better weigh in and validate PASI score reduction HRQoL = health-related quality of life
Thank you Bruce E. Strober; MD; PhD strober@uchc.edu