How can pharmacists help improve outcomes for patients with psoriasis? Dr Rod Tucker Pharmacist/Researcher This session is sponsored by LEO Pharma

Declarations of Interest Dr Tucker has received sponsorship from LEO Pharma.

Psoriasis Psoriasis derived from the Greek word “psora” which means to itch A complex and potentially multifactorial, immune-mediated inflammatory disease Cutaneous symptoms include erythematous/ silvery, hyperkeratotic, scaly plaques Common sites are elbows, knees, scalp, lower back but can occur anywhere

Psoriasis: Epidemiology Affects roughly 2 % of UK population No difference the prevalence between sexes Early onset 15 – 25, late onset 50 – 60 Approximately 50% of all people living with psoriasis have nail involvement

Psoriasis Most common form (over 80%) is plaque psoriasis which is generally life-long, following a relapsing remitting pattern Most patients have mild to moderate disease treatable with topical agents Currently not curable; requires effective self-management

Not just a skin disease

Pathophysiology Related to excessive production of specific cytokines TNF-∝, IL-17A/F IL-17A stimulates keratinocytes & others to drive hyper proliferation of cells IL-17A found in lesional skin & serum & synovial fluid of those with RA

Co-morbidity Increased risk Notes Psoriatic arthritis 35% Crohn’s disease X 2.5 Metabolic syndrome X 2 If psoriasis severe Atrial Fibrillation X 3 If <50 & severe disease Stroke Non-alcoholic fatty liver disease 17 – 60% Skin cancer X 5 uveitis 7 – 20% Depression/Anxiety 1.38 Hazard ratio

In the skin

Psoriasis: causes/triggers Genetic disposition known to be important (roughly a third of patients) Can be triggered by many factors Skin trauma (Koebner’s phenomenon) Climate (often worse in winter than summer) Infections (streptococcal infections) Medicines (anti-malarials, beta-blockers, lithium, NSAIDs, ACE inhibitors) Smoking Stress Alcohol

Patient behaviours increasing risk Smoking Physical inactivity Obesity Excess alcohol Poor adherence (32 – 61% Gupta, 2008)

Plaque psoriasis

Plaque psoriasis

Nail changes

Impact of psoriasis Survey by NPF found that 75% of people said that condition moderate/large impact on quality of life1 1. http://www.psoriasis.org/files/pdfs/press/npfsurvey.pdf

Psoriasis: Topical therapies Emollients Topical steroids Vitamin D analogues Combined steroid-vitamin D compounds Dithranol preparations Coal tar based products Retinoids

Treatment guideline (NICE 2012) Potent topical steroid & vitamin D analogue either alone or in combination applied separately for up to 8 weeks. Next step – vitamin D analogue alone twice daily for up to 12 weeks Next step – potent steroid alone twice daily for 4 weeks OR coal-tar product once or twice daily Next step – if adherence a problem – offer combination product (potent steroid & vitamin D combination product) for 4 weeks Next step – discuss other options or refer to secondary care http://www.nice.org.uk/nicemedia/live/13938/61190/61190.pdf

Patient beliefs Evidence from qualitative studies suggest that: Advice on use of treatments is desired by rarely provided Patients perceived practitioners as lacking in sufficient knowledge to manage psoriasis Lacked empathy Patients want information on condition, co-morbidity, prognosis etc.

The PEDESI Study Aim “To assess patient’s current level of knowledge and understanding of psoriasis and it's management to improve disease outcomes”

Pharmacy recruitment Patients presenting with prescriptions for topical treatments recruited at pharmacy Held an initial consultation and one follow-up 6 weeks later Used the PEDESI tool to assess knowledge SAPASI for disease severity DLQI for quality of life

PEDESI Tool UK/IE MAT-09766 June 2017

SAPASI UK/IE MAT-09766 June 2017

DLQI UK/IE MAT-09766 June 2017

Study outcome measures In total, 47 patients recruited and 42 attended follow-up appointment Follow-up vs baseline in: PEDESI SAPASI DLQI

Change in outcome measures * p< 0.05

Patient follow-up data

Patients level of agreement (n = 38)

What did patients like about the study (n = 38)

Do you think your psoriasis improved as a result of the pharmacist advice?

Pharmacist data

Pharmacist interviews 7 pharmacists interviewed Several themes emerged. Pharmacists saw themselves as: Information providers Members of the management team

Pharmacist interviews Difficulties included: Patient engagement – especially with follow-ups Juggling with demands of other work

Could the service be extended nationally? I’ve seen only 7 patients but after what I’ve seen about how little they know about the treatment and how to use it, what about patients who go to other pharmacies ... It couldn’t be just the few people who are doing the study, it could be everywhere.

Conclusion Psoriasis is not just a chronic skin condition Patients rarely receive sufficient advice from healthcare professionals Pharmacists have a potentially role important educational role to help support patients and improve disease outcomes

How pharmacists can help patients

How the pharmacists helped: Treatment Addition of emollients – helps to soften plaques and improve cosmetic appearance Use of fingertip unit for steroids – 1FTU = one elbow/knee Scalp scaling – use descaling overnight and wash out with tar-shampoo morning

How the pharmacists helped: Lifestyle Stop smoking - reduce trigger Weight reduction – some evidence this helps Exercise – improve cardiovascular health Reduce alcohol intake

References Gupta et al. J Am Acad Dermatol 2008;59(6):1009–16 Tucker In J Pharm pract 2017; 25(2): 140-46 Tucker SelfCare 2016; 7(4): 18 - 31