Exploring acceptability of 'as required' biologic therapy in psoriasis remission: insights from multistakeholder focus groups

Abstract Biologic therapies have revolutionized psoriasis management and have led to increasing numbers of patients in remission. The current paradigm of care involves individuals continuing biologics indefinitely during remission, which results in a risk of infections, adverse drug reactions, injection burden and cost. ‘As required’ therapy during remission, in which an individual takes their biologic at the first sign of psoriasis recurrence, may help to address these problems. This will be tested in an upcoming National Institute for Health and Care Research-funded feasibility trial to determine acceptability and practicality for patients and clinicians in real-world clinical settings. We sought to understand patient and clinician views on an ‘as needed’ biologic therapy during remission, to inform the design of and participants for the feasibility trial. Using purposive sampling, we recruited 15 individuals with psoriasis (eight women, aged 30–80 years) and nine clinicians. We conducted three focus groups using pre-established topic guides, two with patients and one with clinicians (2 h each, November–December 2022). Focus groups were transcribed through Microsoft Teams. Data analysis comprised an iterative and inductive coding process using NVivo and a reflexive thematic analysis approach. We identified five interdependent themes with further subthemes. The impact of psoriasis relapse was alluded to by patients and clinicians as influencing the acceptability of ‘as required’ therapy. For example, patients with previous difficult-to-treat psoriasis were hesitant to undertake ‘as required’ therapy due to concern about psoriasis flares. Access to medication was a key theme for patients, who highlighted a need for reassurance that they could reaccess their biologic promptly when needed, to prevent their psoriasis from flaring. Patients emphasized the importance of safety monitoring and expressed willingness to trial ‘as required’ therapy given that they will be closely monitored remotely. Patients and clinicians were motivated by reducing the burden of treatment, specifically exposure to side-effects, including uncertain long-term effects of treatment, frequency of injections, flexibility of drug administration and reduced National Health Service costs. Finally, patients were interested in taking ownership of care so that they could tailor their medication to their own psoriasis and lifestyle, and clinicians were keen to enable this for their patients. Focus group discussions indicated that patients and clinicians generally found the concept of ‘as required’ therapy during remission acceptable and a promising model for personalized care. These data will inform the participant material for the feasibility trial, to address concerns regarding reaccessing biological therapy and emphasize that treatment will be reintroduced at the first sign of recurrence rather than when psoriasis flares.