An ongoing experiment with Treat to Target

| Steve Bieler
  • Name: Howard Chang, Woodland, California
  • Age diagnosed: 8
  • Age now: 46
  • Diagnosis: Guttate and plaque psoriasis complicated by eczema
  • Past treatments: “Everything.” Topicals, phototherapy, coal tar, systemics, biologics
  • Current treatment: Medium-strength topical steroids in addition to Otezla (apremilast) and Enbrel (etanercept). Tapering off Neoral (cyclosporine) over the next few weeks.
  • Status: 10 to 15 percent coverage and holding

Howard Chang is a husband, a father, an NPF volunteer, a featured columnist at EverydayHealth and a pastor who cares for hundreds of people. It’s important for him to be ready to handle all of these demands. “Treating myself means I am more effective at my job,” he said.

Chang is in the middle of a transition in his drug regimen and is currently tapering off cyclosporine. “I was on and off cyclosporine for three years. That was too long,” he said.

Cyclosporine is an immunosuppressant drug that can cause kidney problems. Even so, he said, cyclosporine “has been the most consistent and effective drug. If I could take it at a higher dose, I’d be 90 percent clear.” He said the side effects “weren’t bad,” but he still had to have his kidneys monitored.

“The trouble is, whenever I left cyclosporine, the new treatment didn’t work, so I kept coming back,” he said. “Now I’m also using Enbrel and Otezla. I believe they have some synergistic effects. I’m a big combination guy.”

A new way forward

Treat to Target (T2T) is a goal, or treatment target, for psoriasis treatment as developed by NPF’s Medical Board. The goal is to reduce the severity of psoriasis after three months to 1 percent or less of Body Surface Area (BSA), roughly equivalent to the surface area of your palm.

In addition to the treatment target, the Medical Board’s recommendations also offer an alternative: Either a BSA of 3 percent or less, or a 75 percent improvement in BSA.

This goal may have been impossible to achieve just 20 years ago, but with the growing number of treatments available and with an increased understanding of the disease, T2T may become the standard of care for people with psoriasis.

Chang, a 35-year veteran of psoriasis treatments, was immediately intrigued by the concept and wrote about the launch of his personal T2T campaign on our blog in March. At that time, Chang’s dermatologist assessed his psoriasis BSA coverage as 10 to 15 percent.

No silver bullet?

The three-month mark is the first milestone in the T2T program. Chang would love to report that his psoriasis has begun to clear, but instead he’s holding steady. His psoriasis has always been difficult to control; at one point, he was 95 percent covered.

“Treat to Target is challenging. There’s no silver bullet for me,” he said. “I like the target aspect, but not the timing. The timing aspect may not be realistic for me.”

“It can be very disheartening for a patient if they try something and have it not work or cause side effects that require stopping that treatment,” said Dr. Abby Van Voorhees, chair of NPF’s Medical Board and a dermatologist at Eastern Virginia Medical School in Norfolk, Virginia. “Then they get discouraged.”

But, she said, when a patient understands from the outset that he or she may need to try a few different options, it can lead to a much more positive experience.

“Then they come back in with the idea in their mind, ‘This one didn’t work. What’s next?’ As opposed to, ‘This one didn’t work. Now I have no hope,’” she said. “It really very much depends on that individual.” 

Editor’s note: This story appeared in the Fall 2017 issue of Psoriasis Advance, meaning it was written earlier in the summer. We checked back with Chang in early November. His psoriasis is particularly stubborn.

“Months into my Treat to Target experience, I felt disappointed and at a loss what to do next,” he told us. “Hitting those targets took much more effort and time than I expected. But setting the goals kept me focused on reaching them, however many setbacks I faced.”

Chang’s doctor recently put him on a newly approved biologic, Tremfya (guselkumab), and it seems to be having some good effects. His lesions are “slowly fading” and becoming “flatter and less scaly.” Although his health insurance is changing at the end of this year and he’ll lose his longtime dermatologist, “I’m optimistic that clear skin is possible in a couple more months.

“I’m not too worried about what comes next. My experience with Treat to Target so far tells me that obstacles and challenges to reach treatment goals come in many different forms. Keeping the goals in mind, while adopting a flexible attitude, gives me the courage and persistence to overcome them one by one.”

 


Driving Discovery, Creating Community

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