Age-based treatment differences in and reluctance to treating older adults with systemic antipsoriatic therapy – a mixed-method pilot study

Figures & data

Table 1. Survey respondent and interview participant characteristics.

	Respondents survey (n = 73)	Participants interview (n = 10)
Age^a (years), median, range	46 (27 − 64)	38 (28 − 61)
Sex, n (%)
Male	30 (41.1)	5 (50.0)
Female	43 (58.9)	5 (50.0)
Physician subgroup, n (%)
Dermatologists	59 (80.8)	7 (70.0)
Dermatology resident	14 (19.2)	3 (30.0)
Type of medical center^b, n (%)
Academic medical center	45 (60.8)	5 (45.4)
General hospital	25 (33.8)	5 (45.4)
Private practice	11 (14.9)	1 (9.1)
Experience with psoriasis treatment (years), median, range	15 (2 − 35)	13 (2 − 31)
Number of patients (≥65 years) currently under treatment with systemic antipsoriatic therapy, median, range	15 (0 − 150)	15 (0 − 150)
Prescribed systemic antipsoriatic therapy, despite of age, n (%)
Methotrexate	73 (100)	10 (100)
Dimethyl fumarate	73 (100)	10 (100)
Acitretin	70 (95.9)	10 (100)
Ciclosporin	63 (86.3)	8 (80)
Ustekinumab	66 (90.4)	9 (90)
Adalimumab	64 (87.7)	7 (70)
Etanercept	58 (78.4)	7 (70)
Secukinumab	54 (74.0)	7 (70)
Ixekizumab	32 (43.8)	5 (50)
Guselkumab	27 (37.0)	3 (30)
Infliximab	25 (34.2)	5 (50)
Risankizumab	18 (24.7)	3 (30)
Certolizumab-pegol	16 (21.9)	5 (50)
Brodalumab	15 (20.5)	3 (30)
Tildrakizumab	7 (9.6)	1 (10)
Apremilast	45 (61.6)	5 (50)
No systemic treatment	0 (0.0)	0 (0.0)
Prescribed systemic antipsoriatic therapy in older adults, n (%)
Methotrexate	70 (95.9)	9 (90)
Dimethyl fumarate	53 (72.6)	7 (70)
Acitretin	52 (71.2)	7 (70)
Ciclosporin	26 (35.6)	6 (60)
Ustekinumab	39 (53.4)	5 (50)
Adalimumab	47 (64.4)	5 (50)
Etanercept	28 (38.4)	6 (60)
Secukinumab	19 (26.0)	2 (20)
Ixekizumab	7 (9.6)	2 (20)
Guselkumab	9 (12.3)	2 (20)
Infliximab	9 (12.3)	3 (30)
Risankizumab	3 (4.1)	0 (0)
Certolizumab-pegol	3 (4.1)	1 (10)
Brodalumab	3 (4.1)	1 (10)
Tildrakizumab	2 (2.7)	1 (10)
Apremilast	14 (19.2)	3 (30)
No systemic treatment	1 (1.4)	1 (10)
Unknown	2 (2.7)	0 (0)
Other^c	1 (1.4)	0 (0)

^aMissing: n = 1.

^bRespondents could select more than one answer and one interviewee worked in two medical centers.

^cOther; prednisone.

Table 2. Survey respondent experiences when treating psoriasis in older adult patients with systemic therapy.

	Respondents (n = 73)
The use of systemic antipsoriatic therapy in older adults, n (%)
Older adults less	19 (26.0)
Comparable between older and younger patients	49 (67.1)
Older adults more	1 (1.4)
Unknown	4 (5.5)
Number of respondents performing additional actions when treating older adults with systemic antipsoriatic therapy when compared to younger patients^a, n (%)
Yes	49 (68.1)
No	20 (27.8)
Unknown	3 (4.2)
Additional actions when treating older adults with systemic antipsoriatic^b, n (%)
Extra checks on comorbidity and/or comedication use	37 (75.5)
More frequent consultation with other specialist/GP	24 (49.0)
Prescribing a lower dose than usual	24 (49.0)
More frequent lab controls	19 (38.8)
Steering in the choice of certain medication	11 (22.4)
Start home care or supportive care	9 (18.4)
Extra control appointment in the clinic	5 (10.2)
Reduced prescription of certain systemic antipsoriatic therapy	6 (12.2)
Other^c	5 (10.2)
Reasons to not perform additional actions when treating older adults with systemic antipsoriatic therapy^d, n (%)
Following the Dutch guidelines is sufficient	7 (35.0)
Choosing antipsoriatic therapy is age independent and depends on the presence of comorbidity/comedication	8 (40.0)

GP: general practitioner.

^aMissing: n = 1.

^bReporting of multiple reasons was possible. Percentages calculated with only respondents that performed additional actions when treating older adults with systemic antipsoriatic therapy (n = 49).

^cOther included; less explanation needed (n = 1), depending on patient’s cognition involving family more easily (n = 1), more consideration whether the therapy is not worse than the disease (n = 1), additional explanation of a higher risk of infection (n = 1), older patients respond better to Neotigason than younger people (n = 1).

^dReporting of multiple reasons was possible. Percentages calculated with only respondents that did not perform additional actions when treating older adults with systemic antipsoriatic therapy (n = 20).

Table 3. Reluctance amongst survey respondents with systemic antipsoriatic therapy in older adults.

	Respondents (n = 73)
Number of respondents thinking their colleagues are reluctant to use systemic antipsoriatic therapy in older adults, n (%)
Yes	33 (45.2)
No	14 (19.2)
Unknown	26 (35.6)
Number of respondents reluctant with the use of systemic antipsoriatic therapy in older adults, n (%)
Yes	20 (27.4)
No	50 (68.5)
Unknown	3 (4.1)
Number of reasons to be reluctant^a, n (%)
Presence of comorbidity	19 (95.0)
Presence of comedication	17 (85.0)
Risk of adverse events	15 (75.0)
Treatment goals/preferences of the patient	9 (45.0)
Cognitive state of the patient	7 (35.0)
Inexperience with systemic antipsoriatic therapy in older patients	3 (15.0)
Degree of self-reliance (e.g. need of homecare)	2 (10.0)
Limited evidence available regarding treatment safety	2 (10.0)
Other^b	5 (25.0)

^aReporting of multiple reasons was possible. Percentages calculated with only respondents that were reluctant with systemic antipsoriatic therapy in older adults (n = 20).

^bOther included; limited evidence available regarding treatment efficacy (n = 1), increased risk of infections (n = 1), (limiting) number of outpatient visits (n = 1), mobility of the patient (n = 1), social network/informal care (n = 1).

Table 4. Comparison of comfort levels of respondents when using systemic antipsoriatic therapy in older adults.

Systemic therapy, n (%)	Mean score^a ± SD	Very comfortable	Comfortable	Neutral	Uncomfortable	Very uncomfortable	95%CI	p-value^b
Methotrexate	4.26 ± 0.6	23 (32.9)	42 (60.0)	5 (7.1)	0 (0.0)	0 (0.0)	4.04 … 4.41	Reference
Ciclosporin	2.82 ± 1.1	4 (6.1)	15 (22.7)	17 (25.8)	25 (37.9)	5 (7.6)	–1.63 … −1.22	<.001
Acitretin	4.18 ± 0.6	18 (27.7)	42 (64.6)	4 (6.2)	1 (1.5)	0 (0.0)	−0.31 … 0.09	1.000
Dimethyl fumarate	3.99 ± 0.7	14 (20.6)	41 (60.3)	11 (16.2)	2 (2.9)	0 (0.0)	−0.47 … −0.07	.113
Etanercept	4.00 ± 0.8	14 (29.2)	22 (45.8)	10 (20.8)	2 (4.2)	0 (0.0)	−0.49 … −0.04	.273
Adalimumab	4.03 ± 0.7	15 (25.4)	32 (54.2)	11 (18.6)	1 (1.7)	0 (0.0)	−0.39 … 0.02	1.000
Infliximab	3.12 ± 1.2	5 (15.2)	9 (27.3)	7 (21.2)	9 (27.3)	3 (9.1)	−1.34 … −0.83	<.001
Ustekinumab	4.03 ± 0.7	14 (22.6)	38 (61.3)	8 (12.9)	2 (3.2)	0 (0.0)	−0.39 … 0.03	1.000
Secukinumab	3.98 ± 0.8	12 (25.0)	25 (52.1)	9 (18.8)	2 (4.2)	0 (0.0)	−0.46 … −0.02	.508
Ixekizumab	3.85 ± 0.9	10 (29.4)	11 (32.4)	11 (32.4)	2 (5.9)	0 (0.0)	−0.66 … −0.15	.024
Certolizumab-pegol	3.86 ± 1.1	8 (38.1)	4 (19.0)	7 (33.3)	2 (9.5)	0 (0.0)	−0.80 … −0.20	.016
Brodalumab	3.78 ± 1.0	8 (34.8)	4 (17.4)	9 (39.1)	2 (8.7)	0 (0.0)	−0.79 … −0.21	.010
Guselkumab	3.89 ± 0.9	11 (31.4)	11 (31.4)	11 (31.4)	2 (5.7)	0 (0.0)	−0.63 … −0.14	.032
Tildrakizumab	3.79 ± 1.1	9 (37.5)	3 (12.5)	10 (41.7)	2 (8.3)	0 (0.0)	−0.77 … −0.20	.014
Risankizumab	3.79 ± 1.0	9 (32.1)	6 (21.4)	11 (39.3)	2 (7.1)	0 (0.0)	−0.78 … −0.24	.003
Apremilast	4.00 ± 0.8	11 (28.2)	17 (43.6)	11 (28.2)	0 (0.0)	0 (0.0)	−0.45 … 0.02	1.000

Values might not add up to missing values.

SD: standard deviation; CI: confidence interval.

^aOverall mean score per treatment. Comfort-levels were measured using a 5-point Likert scale, 5 indicating very comfortable, 1 indicating very uncomfortable.

^bCorrected for multiple testing using Bonferroni.

Table 5. Overview of the key themes, subthemes and codes, emerged from the interview analysis regarding systemic antipsoriatic therapy in older adults.

Key themes	Sub themes	Codes
Challenges and barriers when prescribing systemic therapy in older adults with psoriasis	Prescribing patterns; age-based treatment (in)equality Frailty Comorbidity/comedication Other patient characteristics Prescriber characteristics	Age-based treatment (in)equality Equality ○Equal treatment ○Following the Dutch guidelines; no extra lab controls ○Depending on disease severity ○Shared-decision making ○Elderly is not aged ≥65 years Inequality ○More cautious not reluctant, higher threshold ○Fear of AEs specifically irreversible AEs ○Presence of under treatment; patient-related, prescriber-related ○Suspected difference in treatment goals ○Frailty; mobility, social support, cognitive state, medication errors ○Reluctance of patients’ family members ○Actions: dose adjustments, more precise lab controls, more precise with supplying information, consultation of other specialists, actively checking patient understanding of treatment use Frailty ○Cognitive state/ patient comprehensibility ○Mobility ○Social support/surroundings ○Comorbidity/comedication/polypharmacy Comorbidity/comedication ○Reluctant due to comorbidity/comedication Other patient characteristics ○Perceived reluctancy ○Perceived treatment goals ○Patient competency/resilience ○Therapy compliance Prescriber characteristics ○Feeling competent ○Fear of occurrence of AEs ○Fear of misjudging cognition ○Experience/education of prescriber ○Reluctance of colleagues, generation of physicians ○Guidelines can be complex ○Limited time clinical visits
Physicians’ needs when treating older adults with psoriasis	Evidence-based guidance Education Health care system adjustments No needs	Evidence-based guidance ○Psoriasis guidelines; additional information regarding older adults, compact overview of treatments, if applicable other dosing regiments, specific contra-indications, influence of systemic antipsoriatic therapy on mobility, treatment related AEs or related due to age. ○Large prospective studies on older adults with psoriasis Education ○More attention for older adults in residency ○Education for all physicians on older adults Health care system adjustments ○More consultation time when needed ○Information leaflets for older adults No needs ○No need for additional information on older adults in guidelines or education
Future recommendations when treating older adults with psoriasis	Patient centered care Safety measures	Patient centered care ○Information provision specially for older adults ○Assessment of frailty and acting accordingly/therapy compliance: drug Baxter system, home UV-therapy, involving social support system Safety measures ○Support at the outpatient clinic e.g. deployment of nurse practitioners ○Standard coordination/communication with social support system

AEs: adverse events.