Compliance, Adherence - Whatever, Just Put the D*mn Cream On...

[music] Welcome to Derms on Drugs. A video podcast brought to you by scholars in medicine. Derms on Drugs is where cutting-edge dirt meets low to mediocre comedy. Matt Zeyers and each week I'm joined by my residency buddies Laura Ferris and Tim Patton to use our 60 years of combined-derm experience to discuss debate and dissect the hottest topics in dermatology. It's everything you need to know to be on the cutting edge of Derm and it'll be the most fun you've ever had while actually learning something useful. So tune in every Friday only at scholars in medicine, Spotify and Apple Podcasts. And everybody got to tell you I am so excited today for our deep dive. We've got one of my fattening, no if I'd say one of them, one of. We may be my favorite person in all of Dermatology. We've got Dr. Steve Feldman from Wake Forest University to talk about some of the aspects of adherence, right? We're supposed to call it adherence, not compliance, but it is going to be a great discussion about what do we expect with some of these drugs and should they be better or worse and all that kind of stuff. But let's go ahead and get into it. I'm going to kick it over to Dr. Ferris for our first article of the week. Thanks Matt. I hope I am your second favorite North Carolinian. But I'll start with so I am going to talk about Frontier 2, a Phase 2B Long-term Extension study of the oral peptide J&J2113, which now we can actually call by its proper name, Icochiricinra, for moderate to severe plaque type psoriasis. So what is this drug? This is an oral peptide, so it is administered orally, but it actually binds, it's a small peptide, it escapes the gut and it goes into the bloodstream and it binds to and blocks the IL-23 receptor. Ferris, how does that, so your first I'm going to tell you about Dr. Ferris' first author on this paper, so I think it refers the world expert on, how do you say it again? Icochiricinra. Icochiricinra. How do I'm going to find out I'm saying it wrong? So how does it get absorbed? Like it's a peptide, it shouldn't get, like I think of it as having like 1% bioavailability. It has extremely low bioavailability. But it shouldn't have any, it should have zero. It has some, so it is able to, there is a small amount, it is able to escape through the GI tract, so it actually is systemically absorbed. So, is this a proprietary thing that they've got a special way of doing this, or should we expect like in a couple of years Dupies going to have a Dupy oral and. So this is not the only oral peptide, right? So there are other oral inhibitory peptides, particularly of IL-17, there's one. So this is not something that only Johnson & Johnson or Janssen has. Do I have the recipe and can I make it up in my kitchen? No. So are there proprietary aspects to it? Yes. Okay, all right, all right. There we go, go ahead. So this is it. So the 16 week data were already published and this is sort of the 52 week extension. So, what did we see, basically what we saw 16 weeks held true, really was kind of nicely consistent out to 52 weeks. Patients who were on placebo, two weeks 16 when they crossed over to the high dose, which was 100 milligrams P O B I D. They caught up and really did just as well as that group basically or similarly. So, what does that top line result look like? Pazzy 75 response of 76.2%, Pazzy 90 of 64.3%, Pazzy 140.5%. So, and then safety wise, really there was like nothing unique here. These patients were tested for TB prior to being and screening. There was kind of nothing exciting, nothing unexpected, no real like GI side effects with this medication. So, you know, yeah, go ahead. Where will we use this? So I'm looking at these numbers. I'm no surrises expert, but it looks to me like this is in the ballpark of maybe better than Estellara, not as good as a cosentics. Is that so? So, that's interesting, you would say that. So, if you look at the data for cosentics, you know, there's lots of studies with cosentics, but it's a Pazzy 100 is about 40% with cosentics. Pazzy 90 is about 57%, so it's a little lower than 64%. If you look at Alumia, Pazzy 75 is like 64%. So, what kind of think of it in the cosentic aluminum? Patent's like mumbling in the background. Yeah, what are you mumbling about? What are you mumbling about, Patent? No, that cosentics in Alumia aren't the gangbuster drugs. Like, I think it's on par kind of in that neighborhood where it's not going to, it doesn't seem like it would touch is the skyrizzy, the term, I, uh, pulse and saline. Right. It's not going to be a skyrizzy. Yeah, Pazzy 152 weeks for skyrizzy is about 60%. Okay. It is not going to be the same. How does, uh, where does so tick-toe shake out? Like, is it going to take on so tick-toe? So tick-toe dead now, we, we have another oral medication or. I think this is way better than so tick-toes data. This is a little bit, a little bit better than so tick-toe, right? And you don't have any of the, the Jack, um, concerns. Yeah, yeah. Safety, profile, jacks cause cancer and heart attacks and men. They do not cause cancer. I'm not sure what's going to happen next, Pat. And that will place it. That's all true. My vociferousness is nothing to do with how much I make from avi or Pfizer or lily. I know I was teasing you. I know that how you feel about that. So I think, you know, not to not make this all about that, but, um, I do think that, you know, there are probably patients who prefer an oral medication. And that is why I'm so excited to talk about this with our guest. But I do think that there are patients who prefer an oral medication. But highest dose was BID dosing. I think that's probably a little bit of a deal breaker. But they do have their phase three data or phase three trial. They're doing 200 Q day. And their, um, their top line results have not come out in the literature, but they've come out and press releases. And, um, it's about 74% IGA zero one, about 65% Pazzy 90. That's what's been released. Top line. So, you know, kind of a good consistency. You know, good safety. If you're like, what's the Achilles heel with the oral dosing, you have, they are through the studies it was done on sort of a fasted state. So like 30 minutes before, like in the morning, 30 minutes before you eat, it depends like, is that a deal breaker for most people? And it's not like, you know, it, you know, like you explode if you have it on it. It just means you probably have a little bit more bioavailable. A little bit less. That would be a horrible side of it. Be horrible. You'd be like Gremlins. Don't, don't feed them after midnight. You need a TB test. You need a TB test. You might explode and you may get an infection. Like, what was that? Like, come on. The TB test. Yeah. So I, you know, I think for patients who want biologic, like, you know, safety and, but want an oral medication and want, you know, what is pretty darn good efficacy? I mean, you know, it's not like, Cocentics does not meet sky-rises. Pazie 100 results, but like all of us have patients on Cocentics are clear and happy. So, yeah, we're only getting the same. So, all right. We'll come on that one. Okay. All right. We're going to move on to our second article. That one is mine. Uh, so here we're going to talk about the, uh, Vitamia, uh, atopic dermatitis studies. So to piteroff cream, 1% once daily. So you have an efficacy in the treatment of severe, moderate severe atopic dermatitis and adults and kids end a two years of age in the pivotal phase treatment. Doring trials. Keep take away here at eight weeks, uh, about 45% of people got to IJ zero or one, uh, and then on placebo was only about 15%. So really good efficacy. Uh, you know, here are the interesting things. So first, the, you know, I would like to compare it to obsular as efficacy. So I am a believer that you generally can compare, uh, phase three efficacy results and they're pretty predictive. But, uh, obsular as trials were with mild to moderate atopic dermatitis. Uh, and we know that the more mild AD is the more responsive it is to therapy, that's been, uh, published. So we can't really compare it very well to obsular as data. Uh, you know, the other things that are interesting here, it is approved on to age two right out of the get go. I think this will be a great, I think it'll be a, I don't say great, a really easy drug to talk to parents about because it's a naturally. derived molecule, literally to pinner off comes from worm poop that is where they discovered to pinner off. And there's next to, I mean, there's essentially zero systemic absorption. So there'll be no box wardings. It's very well tolerated. It doesn't sting or burn in anybody. And it works well. So this is the first drug we're going to have in little kids that doesn't have any baggage. Right? The follicularity is 10%, but other than that, no baggage, right? It's not like Eucrissa that burns and stings. It works better than Eucrissa. It's not like TCI's that sting and have a box warning. It's not like Opsilura that's got a box warning. So it's got like it's effective. It's fast and there's no baggage. It really, to me, is an interesting thing to see how much, if this is going to change pediatric AD in the same way that Opsilura changed adult AD. Do you like it because you like contact dermatitis so much and you just kind of be like another business, rather robbery stream. So there was no contact dermatitis in the atopic dermatitis trials. And so the, no, there wasn't. It was only in psoriasis. And they believe that that's because of the TAMA normalizes cytokine levels. So if you've got elevated IL-17 and you drop it, you get a little bit of rebound of IL-13, IL-4-TH2. And so you can get a little dermatitis. Same thing happens whenever you bring IL-13 down, you get a little rebound probably of IL-17, but it doesn't last long enough to start to see psoriasis-y stuff. Now that's the theory who knows. The flakeolitis is definitely still there. I did this trial. I had a lot of kids and I would say, yeah, I was about one in 10. I think it's a little harder in AD because AD, like if new spots show up, that could just be AD, right? Whereas in psoriasis, new spots don't usually show up so you knew that it was the flakeolitis. But one of the, I'm excited to talk to Dr. Feldman about this drug because it's the idea to me of how much of the benefit is just going to be that from a compliance first, put this cream on wherever your kid has an XM, whenever they grab XM versus like, well, don't use this steroid there. Don't use that steroid here. Don't use it longer than this. Moisturize three times a day. Take two baths. Like, is it more than just the efficacy of the drug, right? And that's going to be interesting. So you guys, it's fairly straightforward here. One here, I think. You guys got comments? So how do you think this is going to compare to Zoreve? So most recent Zoreve data are out, right? So this was like 45% and I think it had an IGA response, right? Yes. With to pin her off. And with Zoreve, it's like 35%, right? Yes. So do you think that's going to be meaningfully different? Or is this going to be like, well, there's kind of like not a lot to worry about. You don't have the folliculitis. Do you think that there's going to be this spin of like, is this, I mean, this is a novel mechanism of action with to pin her off, right? There is sort of this arrow hydrocarbon receptor agonism. You can sort of, you could say it's worm poop, but you could also say, oh, it's sort of like the same pathway as dioxin too, right? So we don't know what ton about this pathway to say. It's 100% as safe as rubbing worms on your skin. Yeah. It's a fascinating question. So I don't know how I think Pied's Derms will like Zoreve better because it's a known MOA, right? It's basically if you're a Pied's Derm, you can think of, you can think of Zoreve as more effective Eucrissa that doesn't burn, right? And they really like Eucrissa. I don't think they really like Eucrissa, but they like safety of it. My guess is that adult terms will use more vatama because they're less sort of safety, they're still safety concerned, but not as much as Pied's Derms. That would be my guess as to what's going to happen in the market. I don't think we'll ever see a head to head of the two drugs unless somebody does it like a small, you know, 20 people on one, 20 people on the other, but neither companies ever going to pay for it. So it's an interesting question. Like I don't, I suspect I think based on the data that vatama is a more effective drug, but right, it's got the polluculitis, it's got a new mechanism of action. I could see it going either way because they go in either way. All right. But you said opposite, they would change the same way, absolute change, adult atopic term. Like are you blown away by absolute or not a adult atopic? Absolutely. I think as close as we will ever get. So right, they've got pretty good data that the anti-h effect happens in 15 minutes. And by real world experience with it, it mirrors the trials, which the trials say with as needed use, 75% of people are clear, almost clear, long term. And that's like, I have not had, like I haven't been blown away by it. Like it's not like people are coming back like, oh my gosh, that drug was the best thing I've ever used. I mean, I've had people come back that are like, yeah, it does, you know, it's really hard to get number one. Yeah. So it took me forever. And, you know, it's like, yeah, I'll just use my hydrochordism. I don't use it that way. I love it. I love it. It's relief in 15 minutes, not counting the two weeks that took you to actually. Yeah. My ex and I just went away by the time I got it. So I truly think of it as clubatism without having to worry about like all the other stuff. But I'm, yeah, I'm biased towards all new pharmaceuticals. So you know, take, take everything with a grain of salt. All right. Let's, let's go into our third article, Dr. Patton. Yeah. Yeah. We've got a few years, 2022 American Journal of Clinical Dermatology, Stein Goldett, I'll efficacy and safety of a fixed dose, clindamycin phosphate, benzoproxide, adapoline gel for Moderna, Tra-Serveer, Acne, randomised phase two study. The first triple combination drug. So this is Cabtrio, right? Dr. Felman at a recent publication about Cabtrio for weeks. We'll get into that with him. I just kind of went back to the original. Like, I haven't prescribed this. I don't think I've had a patient come in and say, I love my Cabtrio. Can I get some more? So I just wanted to go to the original study, kind of look what it looked like. You know, it has the three things. BPO and adapoline are micronized and it's a gel. So it distributes more evenly on the skin. All this information was in the intro sounded good to me. Patients had Moderna, Tra-Serveer, Acne, they had to have, you know, so many inflammatory non-inflammatory lesions. They couldn't have bad nodular acne. And they were randomised to either get the triple cream or like the die ads, you know, just two of the three. Clinda BPO versus BPO, adapoline versus adapoline, Clinda, or vehicle about 150 patients in each arm. Multi-center double blind blood. So treatment, Table 2 shows the treatment success. So this is at least a two-point improvement in EGSS. What was it? Evaluate or Global Severity Score? And being either clear or almost clear at 12 weeks, 50% for Cabtrio and the die ads it was like in the 30s. So this drug is awesome. You go to Figure 2, Improvements in Flamatory Acne, Non-inflammatory lesions. But this is where it's kind of like, what, this isn't that good. So what do you want to say? The numbers, let's say patients started with 50 inflammatory papillages on their face. At 12 weeks, if they use Cabtrio, they'd have about 12 lesions, if my mouth is right. And if they use Clinda BPO, which is like the worst die ad, they would have 18. So a kid who uses Cabtrio is not going to look at the kid who use a diet and be like, my acne is way better than that kid. They'd be like, that kid has acne just like I do. One inflammatory lesions were better. And then what killed me about this trial was the quality of life measures, right? That's all that matters for acne. Like is the patient happy with their acne within some patients? For like exploding. Yeah, exactly. So as Cabtrio statistically significantly better at anything else in quality of life measures, like I don't think it was because the authors specifically say improvements in acne quality of life scores at week 12 were numerically greater. That's the word that you use when it's not statistically significantly greater, right? True, true. So it's not, it's not any better. In terms of what matters for acne, it's not any better than any of the die ads. And so like why is it being sold to us this way? And you know, I don't want to get into industry funded, you know, they hired scientific writers that are acknowledged that actually aren't authors on the paper. Every medical every drug is industry funded. But in everybody has hires writers, right? I mean, don't put it in your money. I was hired writers. This is an advertiser. It's we have residents for this is an advertisement by the company that's mass grading itself as a, you know, like an independent scientific inquiry. But it's an ad. That's every face three that seems as higher as saying it's all a problem. Like don't do it this way. I actually would think it's a, you know, You were saying this and I was thinking about it, it does make a ton of sense that companies should just put all of their date. Like I should be able to go to every drug's website. And like the meat and almost the raw data be there and like be able to do that instead of putting in journals. - Right, so have a website. Here's a link to our study. It was FDA, like it's still, that doesn't make it any worse of a study. FDA will still improve it. They have to meet all those requirements. Here's our raw data. You can have access to that. The drug companies don't do that either. You can't see the raw data. And they sell it to you in the most, it's deceptive, right? - But then the jab wouldn't have anybody advertising. And they agree, it's all a problem. - You know? - It's all a problem. Now, is it like, do I really care? I mean, I don't really care. And actually, I, cab tree was, like it's kind of a nice drug if you think about it, right? I mean. But in acne, it's hard to, we've got a drug that gets 80% of people 100% clear for the rest of their life, right? My daughter's got three pimples, and I say, you're going on acutane. And like, it's hard for me to understand why we even try and treat acne topically. - They have four patients. And I would say all of them I would have said, there's this really good drug. And you might be clear in four, five, or six months. Like, this is the thing, like they say, oh, acne requires long-term treatment. Like, no, it doesn't. And if I was an author on this, I would say, let's not say that, because that's not true. They say one part, like, why even add clindin here? Like, topical antibiotics don't make any sense to me. Bacterial resistance. I know it's lower with BPO, but it could be zero with not adding clinda. And they have this, they say, well, adding clinda increases the antibacterial activity of BPO, or something of how it increases it. And then they have a reference. And that's not what that reference says. Like, I think of the study for the reference. I'm like, it says nowhere in here that clinda adds to the antibacterial of BPO. And I used AI even, Matt, because, you know, it's better than us. I'm like, AI, does this paper actually show that it increases antibacterial activity of BPO? And they're like, no, I can't see that. So it's all very selective. It's deceptive. I don't like it. I don't like these studies. That's wonderful. So Ferris, take away is we don't let Pat and review any more Pharma article. That's exactly. That's how we handle this kind of descent. You're limited in case reports. It's not going to change. Well, let's move on and bring our guests on. So as I mentioned at the beginning here, I'm so excited to have Dr. Steve Feldman on. So one of the lectures I remember very clearly from early in my career was a Pennsylvania Academy of Dermatology Meeting, where I saw Dr. Feldman lecturing about psoriasis. And he taught me some of the stuff that I still use to this day and think about them when I use it. That I touch every patient with psoriasis. So they know I don't think they're gross. And that I don't think that that's their contagious or whatever. I sit down with people. I talk to them like a normal whatever. But I had just learned so much from Dr. Feldman over the years about compliance or adherence. I'm so excited to have him on. So Steve, great to have you here. And I am actually, we're going to start by kind of letting Dr. Patton put it sort of ask some about this new four week cab trio article that just came out. But I guess before we get to that, anything you any comments on our discussion up till now, any thoughts? - Yes. First of all, thank you so much for having me. Your discussion so far has been highly entertaining. And what I really appreciate the most is that you chose three articles that are all about patient adherence. - That's why we did it. - That's literally what we were like. We were like, we were at Steve Feldman on. We're going to have this. So let's get into it. Patton, go ahead. - Yeah, so Steve, you had one article. It was a long time ago, but it was basically how compliant, I think it was an acne study. And it was like one single cream and basically compliance was, I mean, it was just horrific. Right? I mean, patients do not use their acne cream. - Are you serious? (laughing) - I, like that one blow me away, but the number was so terrible. I mean, my kids have acne and they're actually okay. I was very surprised at that number. It was zero. That was the, that's why you were surprised. It was not a single per, it was the one where he had the little cap on the electronic cap. - He measured it. - Not a single person used it 80% of the time, not one. - So something like Cab trio, with what I think is a clinically minimal difference, but because it's three and one, it's once a day, but you showed compliance, really wasn't that good for if you're just using even something once a day. Do you think Cab trio makes a big difference in that? - Well, big difference is, big is, is hard to define. I may think it makes a difference, sure. You mentioned that there was not a big difference if they used the triple versus using the diad. Be very careful with your language. There was very little, there was difference between the group assigned to use the triple versus the group assigned to use the diad. - There was a lot of use there. - You know, when residents say, "Oh, the patient is using XYZ," I'm like, "Are you in the room with them watching?" You know, if not, then you should say, they say they're using. They claim they're using allegedly, they're using XYZ, okay? - Yeah. - And this theme runs through all three of these papers 'cause you go, "Well, this oral aisle, 23 blocker is not as effective as injectable aisle, 23 blocker." Well, what is the mechanism for that? If you're blocking aisle, 23, they should work the same well. Maybe they're not taking all the pills. I know this is shocking, but. (laughs) The patients aren't always fully adhering to their treatments. - But do you think they're better in trials though? 'Cause we did this and it's like they had like a card and they had the blister packs. Do you think that that helps? Or do you think they're like, "Oh, I got my study appointment." Like pop, pop, pop, pop. There you go. - Well, they're both. Yeah, now that you mentioned it, the pop, pop, pop, I'm sure that's happening. But I think blister packs are much better and they've been proven much better. Because in the 1960s birth control pills worked okay, but not great. They didn't change the chemistry. They just changed the packaging to tell you what pill to take what day and they became dramatically more effective. - Huh. - But the. - Why are we. - Yeah, the pill should be packaged in a bottle, especially a beige bottle that's designed to blend into the natural environment. It's like, though somebody was intentionally trying to make people. Or look, I would make pink bottles and blue bottles. Laura, you know who the pink bottles are for, right? - What are those are. No, that's top of this mall. (laughing) - I mean, I put triam, synalone, and pink bottles and blue bottles. The blue bottle, Tim would be for the. - Boys. - Boys. - You are so not woke. No, whoever wants them. (laughing) - Oh. That was a trick question. - I was. It was a trick question. - I am politically sensitive, which is why I said Pepto is. (laughing) - Yeah. - That was a better answer. - So, but also in the trials, they're bringing patients back a week's 1, 2, 4, 6, 8, 12. And those visits dramatically increase in here. It's based on what Tim has said about the poor response of his patients to, you know, topical opsalora, to the acne medicines. I'm pretty sure he's not bringing the patients back a week's 1, 2, 4, 6. He's probably telling people here, use this, see it three months. Do what would happen if a piano teacher said, "Here's your sheet music, practice every day. "I'm not gonna have weekly lessons with you. "I'll just see you at the recital in three months." That recital is gonna sound abysmal. And dermatologists are worse than that. You know, dermatologists would be like a piano teacher saying, "Here's a prescription for some sheet music. "Take it to the sheet music store. "I have no idea what's gonna cost you." I want you to practice this sheet music every day. Now, you may, if you do, you may get rashes diarrhea, possibly a serious infection. But I want you to practice every day. I will see you at the recital in three months. After recital doesn't sound good, which it often doesn't. I will give you a second and possibly a third musical instrument to practice at the same time. So, Steve, you're reminding me of something. So years ago, you and I were lecturing together and I was going on about how great serivies and it's like a miracle and blah, blah, blah. And you're like, "Matt, do you think maybe the reason "you think serivie works so well is because you're telling "your patients, oh my God, this is a miracle." It's the blah, and I actually, like first I was like, "You might be right, but then I took that home and now, "so here's my spillo whenever I'm doing "obsular for a patient. "This is like a miracle, you're gonna put it on "and your ex-imm is gonna be better right away. "It's completely safe." And you know what? stuff is so good, it's like a $2,000 a tube, but I'm going to be able to get it for you cheaper, but it's worth it. It's so good. Whereas I bet patents is more like this drug cuts, no better than anything else. It's too expensive. They shouldn't have made it. Wait a minute. It may not be, it may not be any more effective than triumphant sinolone. I think Opsilord does have like a head to head with, with tax study and it, it didn't really blow tack away. It was more effective than the track in that head. It was twice as effective. But here's the problem, Tim. You're not giving Opsilord a first. You're giving triumphant sinolone first. And when you do, all the people who do well on it, all the adherent patients, they're do great and they stay on it. All the non-adherent patients who don't put their topicals on are the only ones you're prescribing the Opsilord to. So you have selected for non-adherent patients when you're treating them with Opsilord. And despite that, it still works some, which is probably dramatically effective. It's kind of like tar in psoriasis, which by the way, same medical action to pin it off. The fact that it worked it all proves that it's extraordinarily effective because it is so messy. God knows people can't put it on. I love it when somebody outsmarts patent, right? That it's the. You're so smart. I like it for the non-compliant people. Oh, that's good. Without question. Yeah. I mean, Steve, do you think the real. Like, you're been working on adherence for decades. Do you think the answer is, we're going to figure out how to get people to be adherent? Or do you think the answer is, we just need to come up with drugs that are ready to prove. Give yourself a shot once every three months, like, and that's it. Like, we should. is it even worth trying to get people to be more adherent? Was published a study on the long-term adherence to topical fluous synonyde for psoriasis? I couldn't use chlobatis, because I wanted people to be able to use it every day. I wanted people to use it every day. The adherence, you know, along with so abysmal, that the British Journal of Dermatology, let me put the word abysmal in the title of the paper. (Laughter) Chad, didn't want the word abysmal in the paper. I'm like, I'll go the Fritz. They'll let me put it in there. Yeah. I think you can get people to use the medicines. I think you can. But you have to be willing to do stuff. Now, for example, you can use. for a patient who has resistant atopic dermatitis, what you can do is bring the office for phototherapy treatments on a daily basis and explain to them to bring their triumphant synonyllum awayment so that you can apply it to their ointment, to their dermatitis every day so that the light will penetrate better. Because as you know, the scale reflects light. If you just put some of that triumphant ointment on, the light will penetrate better. And if you don't have a light box, you just use a wood slant for this. Because the point is, the point is you're going to make sure that that topple gets on them every day. Now, it doesn't take a lot. And the bright, you probably don't need obsular because if you did put the triumphant ointment on, they would clear up. Because y'all, I know all three of you have probably admitted patients to the hospital with resistant atopic dermatitis. And you put triumphant ointment on them in the hospital. And they cleared up in two to three days. I mean, from total body-like, unified dermatitis to clear in three days with triumphant ointment. It's not that you're taking them away from the dust mites at home, which is what I was told when I was arrested or that you're taking them away from the stress of the home environment. So all you got to just get people to start on the drug. You use it really well for three days. So if you give them an office visit in three days, it would be like a dentist telling you, "I'm really worried about your gums. I want you to floss every day. I'm going to see you back here in three days." People who've never floss before will floss those three days. And then if you don't want to bring them back, you tell them, "Here's my cell phone number. You call me in three days." Makes a dramatic impact on the use of the medicine. I've been theorizing that every time my electronic medical record sees that I not write a new prescription for the patient, it will send the patient a deep fake of me. My face, my voice talking to them, saying, "Hey, we started you on this medicine. I'm going to call you back. I'm going to come back to you in three days." You notice, "Fine dad, how you're doing." And then they're thinking they're going to talk to me in three days, but it will be the deep fake. It will be electrons. It will cost nothing to create the sense of accountability that drives people's behavior. You know what I mean? So for acne, though, I want to say, if the presence of acne and how much it bothers you, that needs to be the driver. If you come back to me in three months and were honest and said, "I wasn't great about using this." That's not my problem. We have very little time as it is. I think that becomes so hard when I take a medication, I have blood pressure, I take it every day. If I went back in three months to my doc and was like, "I'm not really doing it," I wouldn't say to her, "Wow, you need to help me take it more." I would say, "I need to take this." So, Steve, did you say-- I need too much to say about this. The patients think they're using it. So there's a difference between their lying. I'm not really using it, but I'm going to pretend I am. I put it on every day, but really they didn't put it on every day. They just don't know. Each of the two, because that gets to Patent's question. If it's that they think they're using it, then I feel like it's more on us. If they know they're not using it, then I kind of agree with them that it's more on them. Well, it's clearly on us. Dermatologist Danny Berg once told me about this wisdom from a Vietnamese Buddhist monk named Tik Nhat Han who said, "If the lettuce is not growing well, you don't blame the lettuce." All right. You're not letting the lettuce get chewed. You know, it's all your fault to him for telling them to come back in three months. If you have a student who's at the top of their medical school class who's desperate to get a dermatology residency who is as bright and as justrious as anybody on the planet, would you tell them who comes to work with you over the summer and what's the published? Would you tell them, "Here's your project. Work on this every day. I'll meet with you again at the end of the summer." No, it would be ridiculous. You would have weekly lab meetings with them that would make them work. I think you're right, Matt, that they don't even realize how little they're using it. But the idea that they're bothered by their disease is going to make them work, make them use the medicine. It's simply wrong. This example of this is a story I got to tell when the dean invited me to speak to all the big donors of our medical center. And I'd given my adherestock in the dean who's a hypertension doctor said, "You know, I'm really shocked. Your patients aren't using the medicine. It doesn't make sense to me. I take care of diabetes and hypertension, silent diseases. But you're taking care of diseases where the patients are itching or in pain and they see their relations. I would think they'd be adhered to the treatment." And I said to the dean, "In medical school, they taught me nothing about adherence. I use this book, Goodman and Gilman for Pharmacology. Massive textbook, really thin sheets of paper covered everything that affected drugs except for the three most important things, which is whether they use it, whether they use it, whether they use it. But I was at the VA. I admitted a patient with sexually transmitted disease. And I'm reading everything I can find about sexually transmitted diseases because I'm going to get pimped at Duke the next morning on rounds. And I read that if you have gonorrhea, you could cure it by taking a pill daily for seven days. That's all you got to do. You take the antibiotic pill for seven days and you're cured. But we do not treat people that way. We inject them with penicillin because you can't count on people taking a pill consistently for just seven days for gonorrhea. Now I know psoriasis bed. I know that they probably have some horrible. But if I had gonorrhea, if I had this painful, gripping out, okay, I would think, I would think that that would affect me socially in my interactions with people. But they won't take a pill. The stuff we ask them to do, the stuff you're asking your agni patient to do for three months. They're not. You know, I just realized like acutain works so well. Like to me, I was like acutain works because patients are motivated and they want to take it. But you have to see those patients every month because of the whole eye pledge thing. So now I'm realizing. And giving that set. Yeah. Yeah. That's a part of it. Acutain works really well. It's good for giving drug. If you miss a dose, probably doesn't matter because the half life is so long. And but the next time you see an acutain patient, what I would like you to do is simply ask them if they're taking it regularly. But this is how I want you to phrase the question. Sometimes we get gaps between these monthly visits. Do you have enough extra pills on hand to carry you through? through those gaps. Now if they say yes, that means they are not taking it regularly. - Yeah. And they're in blister packs. That's the other part of that. - Yeah. - Well, Steve, it has been a ball talking about compliance. And I think we're ready to move on to what is universally everyone's favorite segment of the show. Pat and trivia. Pat, what do you got for us this week? - Okay, so pay attention. This is harder than prescribing an acne regimen. All right, the title of this trivia, it's called biosimilars or science fiction. I have seven names in front of me here. It's either a biosimilar or a name taken from science fiction. So I'm gonna say the name. And you either say science fiction, if you think it's from science fiction, and if you answer it correctly, then it's over what you win. You can't answer more than once, so you can't give two answers. You can't go science fiction or whatever. Now if you think it's a biosimilar, you have to tell me what it is a biosimilar to, either like the first branded that came out or the generic. - Okay. - All right, all right. - Are you serious? - Yep. - And you only get one answer. You can't keep us on on this one. - Okay, so we're gonna, so it's one person at a time, so we'll start. - No, no, no, all three. But you either say science fiction or you name the biosimilar that it is a biosimilar too. - Yep, so do we say biosimilar or do we have to say, like you say the drug? - Yes, so you say, - Okay, it's okay. - Or whatever, right? - All right, all right, all right. - Okay, ready? First one, we got seven of these. It should go pretty quickly, so that we should do this. First one, Simlandi. - Biosimilar. - Two. - Sipzia. - No, what's it a biosimilar too? You have to name the drug. - Or add a limbam. - Yep, got it. So that's how you answer. You would answer add a limbamap. - Or humor. - Or humor. - Or humor. You're allowed to use a grand name. - A grand name. - Okay. - Feldman 1, Zyersfair 0. - Yeah. - Second. Ad Solo. It's a biosimilar of, but what is it about? - It's Remake. - Dole Fairs 1, Falcon 1. Ooh, they've got a North Carolina showdown here. - Yes, that's right. - Are you guys tobacco roaders that you and C in Duke? - No, I don't know. I haven't been here a long time. - There's a tobacco road rivalry, okay. Third one, Omellis. - Flying Spiction. - It is science fiction. The Nail of a fictional city in a short story. The ones who walk away from Omellis by Ursula Laguin. - I'll tie it up, one, one, one. - Reab me. - Science fiction. - No. - Yeah. - Remake? - No. - Ritux, oh, I can't. - I've only got one guess. - Yeah, I've not heard of that one. - No guess? Can't hurt. You know, no points. - What's the name of it again? - Reab me. - Yeah, Ritux, man. - Yes, Ritux. - No, oh, oh, oh. - I kinda got to go turn around the house. - Yeah, yeah, yeah. - Better to be lucky than good sometimes. - All right, number five, Irrallon. That's definitely science fiction. That's the name of an elf in something. - It's a name of a princess from Dune. - Okay. - Okay. - Number six, Imuldosa. - Science fiction. (laughing) - This one's great. I got approved at the end of last year. - Stalara. - Yes. - It's two, two, two going into the seventh. - You've only won on science fiction. I'm gonna point that out. - I know more medicine and you know more. - If you said science fiction right away for every question, you'd have the same score you have right now. (laughing) - All right, last and final, two, two, two, this is good. - You fly ma. (laughing) - I've got a science fiction. - No. - That sounds like science fiction. - Oh, look at it. The UNC Wake Forest showed at neither one of the, there's a lot of bragging rights writing on this. - You're fine. - I'll go with the Nembro biosomely. - No. It's all of you Ferris, all the time in the world. What do you got? - I'm gonna go Stalara again. - It's Hubera, it's Adalimima biosomely. - No, I thought I knew all of those. All right, I was looking-- - A three-way tie. - I'm waiting for Julio to come out. That's my favorite name of a Hubera. (laughing) - The Hubera ones are good. The ones that are coming out for Stalara, I mean, they're like every single one sounds like a science fiction character. It's awesome. All right, that was fun guys. It's a three-way tie. (sighs) - All right. - The first ever in the history of the podcast. - Have Germs on Drugs? - It's true. - Wait, Steve, Dr. Feldman, thank you for joining us today. This has been a very, very fun episode. And I wanna thank all of our listeners for joining us this week. If you got questions, comments, ideas for topics which cover on the show, shoot us an email at questions at termsandrugs.com. Again, that's questions at termsandrugs.com. I hope you learned a few things of laughed once or twice, but mostly, I hope you're gonna join us next week. Until then, I'm Matt Cyrus. I'm Tim Patton. - And I'm Laura Ferris and we are Derms on Drugs. (upbeat music)