Managing Psoriasis with Guidelines

Posted by: admin on: May 3, 2012

Being a chronic skin problem, psoriasis needs to be managed with other accompanying medical concerns. Here is a guideline in the use of newer and the conventional drugs and patient compliance.


Newer biologic agents for treating moderate-to-severe plaque psoriasis do not carry the risk of end-organ toxicities found with older, conventional systemic agents and can be considered for first-line use in some cases, according to new psoriasis treatment guidelines from the National Psoriasis Foundation.
On the other hand, conventional drugs such as methotrexate and cyclosporine often are effective, but have significant toxicities, including liver problems with methotrexate and kidney problems with cyclosporine.
Because the biologics don’t have significant end-organ toxicities, “no clinical reason supports reserving the biologicals for second-line use,” the guideline authors stated. “The biological agents used to treat psoriasis represent significant recent additions to the dermatologist’s toolkit.”
The guidelines, which summarize the benefits and drawbacks of systemic agents currently in use for psoriasis, are an update of earlier recommendations developed in Canada.
In comparing the benefits of the conventional oral agents, Hsu and colleagues noted that methotrexate is less effective in clearing plaques than cyclosporine, which can reduce disease severity by 75%. Methotrexate also is teratogenic,.
A third oral agent is the retinoid acitretin (Soriatane), which also is teratogenic and is limited in efficacy, so it often is used as part of a combination regimen. Among the biologic agents, three tumor necrosis factor (TNF) inhibitors all have demonstrated high levels of efficacy in clearing plaque psoriasis.
However, these immunosuppressant agents have been linked with serious infections, autoimmunity, and malignancies.
One TNF inhibitor, etanercept (Enbrel), typically is given in subcutaneous doses of 50 mg twice each week and then once weekly after three months, with 75% improvement in about half of patients. Another TNF inhibitor, “infliximab [Remicade] offers rapid and thorough suppression of psoriasis,” with almost half of patients having a 90% reduction in symptoms in less than three months, the guidelines stated. Adalimumab (Humira), a third TNF inhibitor, is administered in a loading dose of 80 mg, followed by subcutaneous doses of 40 mg every other week, The TNF inhibitor was associated with higher rates of 75%, 90%, and 100% improvements in skin scores as well as with fewer adverse events.
Other biologic options include ustekinumab (Stelara) and alefacept (Amevive), Hsu and colleagues noted.
Ultraviolet light therapy using narrowband UV-B or psoralen UV-A also is effective and continues to be used, despite a risk of carcinogenesis.
The guidelines also addressed systemic treatment for specific patient populations. For example, if treatment is needed during pregnancy, UV-B phototherapy or topical agents such as corticosteroids can be tried, although many women experience spontaneous improvements while pregnant.
Patients with hepatitis B virus infection should not be given methotrexate, the authors noted. For patients found to be seropositive, antiviral treatment is recommended with close follow-up.
In patients with hepatitis C infection being treated with biologic therapies, liver enzymes must be followed and screening for hepatocellular carcinoma must be performed.
Cardiovascular disease is a particular concern in patients with psoriasis, who — like patients with other autoimmune conditions — are at high risk for early cardiac-related mortality.
Because of this, “Clinicians should advocate smoking cessation programs and any other steps to correct modifiable cardiovascular risk factors,” the guidelines state.
In conclusion, Hsu and colleagues encouraged clinicians to be proactive with patients to improve treatment adherence.
“Our hard-won insights on the limits of treatment persistence in the real world will apply, no matter how subtly targeted the treatment options become. Even the most sophisticated drugs work only if the patient takes them.”


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