Treatment of Medicare Patients with Moderate-to-Severe Psoriasis who Cannot Afford Biologics or Apremilast
Elderly patients are a group with a high frequency of psoriasis. Their disease burden has negative impacts on their quality of life. While there is a clear need to treat these patients, there are challenges in doing so. This work seeks to define the challenges that exist in treating elderly Medicare patients, as well as to provide treatment suggestions for providers to follow if they encounter one or more of these challenges. Providers face the following challenges when creating treatment plants for elderly patients with psoriasis: difficulty in obtaining drug coverage through Medicare, increased medical comorbidities, and polypharmacy. Providers aim for regimens that are affordable, safe, and efficacious, but it is not always clear how to achieve this combination, especially in elderly Medicare patients. This work is relevant in that it aims to explain the logistical roadblocks posed by Medicare coverage and provide solutions for commonly encountered issues in the treatment of a disabling and common disease in a high-risk population. Specifically, alternative treatment options to biologics and small-molecule inhibitors are discussed and include topical therapies, phototherapy, methotrexate, acitretin, and cyclosporine and for psoriatic arthritis include corticosteroids and leflunomide. The specific risks and benefits of these therapies in the elderly population are provided, allowing providers to make patient-specific decisions about optimal regimens.
The authors acknowledge Stacie Bell at the National Psoriasis Foundation for her support of this manuscript.
Compliance with Ethical Standards
This project was not funded, and there are no conflicts of interest related to this project.
Conflict of interest
Author disclosures are provided below for full transparency, although none of the authors were compensated for this project. Nicola E. Natsis has been previously hired as a scientific writer for XBiotech USA for unrelated projects. Joseph F. Merola is a consultant and/or investigator for Merck Research Laboratories, Abbvie, Dermavant, Eli Lilly and Company, Novartis, Janssen, UCB, Samumed, Celgene, Sanofi Regeneron, GSK, Almirall, Sun Pharma, Biogen, Pfizer, Incyte, Aclaris, and Leo Pharma. Jeffrey M. Weinberg is an investigator for AbbVie, Amgen, Celgene, Eli Lilly, UCB, BMS, and Novartis and a speaker for AbbVie, Celgene, Novartis, Regeneron, Sun Pharmaceutical, UCB, and Valeant Pharmaceuticals North America LLC. Jashin J. Wu is an investigator for AbbVie, Amgen, Eli Lilly, Janssen, and Novartis; a consultant for AbbVie, Almirall, Amgen, Bristol-Myers Squibb, Celgene, Dermira, Dr. Reddy’s Laboratories, Eli Lilly, Janssen, LEO Pharma, Novartis, Promius Pharma, Regeneron, Sun Pharmaceutical, UCB, and Valeant Pharmaceuticals North America LLC; and a speaker for AbbVie, Celgene, Novartis, Regeneron, Sun Pharmaceutical, UCB, and Valeant Pharmaceuticals North America LLC. Ana-Maria Orbai is a Jerome L. Greene Foundation Scholar and is supported in part by a research grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number P30-AR070254 (Core B). Ana-Maria Orbai received research grants from Abbvie, Celgene, Eli Lilly, Horizon, Janssen, and Novartis and consulting fees from Eli Lilly, Janssen, Novartis, Pfizer, and UCB. Jerry Bagel is a consultant, speaker, and/or investigator for Abbvie, Amgen, BI,BMS, Celgene, Jahnssen, Leo, Eli-Lilly, Novartis, and Ortho-Dermatologics. Alice B. Gottlieb is a consultant/advisory board/speaker bureau member of Janssen Inc., Celgene Corp., Beiersdorf, Bristol Myers Squibb Co., Abbvie, UCB, Novartis, Incyte, Lilly, Reddy Labs, Valeant, Dermira, Allergan, Sun Pharmaceuticals Industries, Xbiotech, Leo, Avotres Therapeutics, and Boeringer Ingelheim. She holds research/educational grants from Janssen, Incyte, Novartis, Xbiotech, UCB, and Boeringer Ingelheim.
- 1.MedPac. The next generation of Medicare beneficiaries. Report to the Congress: Medicare and the health care delivery system. 2015. http://www.medpac.gov/docs/default-source/reports/chapter-2-the-next-generation-of-medicare-beneficiaries-june-2015-report-.pdf?sfvrsn=0. Accessed 19 Aug 2019.
- 3.Center for Medicare Advocacy. Assistance with paying for prescription drugs. 2015. http://www.medicareadvocacy.org/finding-help-to-get-prescription-drugs/. Accessed 19 Aug 2019.
- 6.Tveit KS, Duvetorp A, Østergaard M, Skov L, Danielsen K, Iversen L, et al. Treatment use and satisfaction among patients with psoriasis and psoriatic arthritis: results from the NORdic PAtient survey of Psoriasis and Psoriatic arthritis (NORPAPP). J Eur Acad Dermatol Venereol. 2019;33(2):340–54.CrossRefPubMedGoogle Scholar
- 9.Medina C, Carretero G, Ferrandiz C, Dauden E, Vanaclocha F, Gómez-García FJ, et al. Safety of classic and biologic systemic therapies for the treatment of psoriasis in elderly: an observational study from national BIOBADADERM registry. J Eur Acad Dermatol Venereol. 2015;29(5):858–64.CrossRefPubMedGoogle Scholar
- 28.Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61(3):451–85.CrossRefPubMedGoogle Scholar