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PDAT4 > 27 - Psoriasis > Flashcards

27 - Psoriasis Flashcards

1
Q

Which PSORIASIS DRUG is
PREGNANCY CATEGORY X?

A

TOPICAL RETINOIDS

Tazarotene 0.1% & 0.05% cream/gel

Also:
Methotrexate** + **Acretin

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2
Q

Which SYSTEMIC PSORIASIS Drug?

Calcineurin Inhibitor + Blocks Lymphocytes
T-cells & IL-2 containing lymphokines

Short Term Therapy < 12 weeks
to reduce risk of nephrotoxicity
also need to TAPER off dose for D/C
1mg/kg/day each week to prolong relapse
Rebound Psoriasis very likely

A

CYCLOSPORINE

Moderate - Severe Plaque Psoriasis
for inducing remission & maintanence

CYP34A SUBSTRATE

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3
Q

AMJEVITA
is a Biosimilar to BRM?

A

ADALIMUMAB = Humira
starts with A

TNF-a inhibitor

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4
Q

ACRETIN - ADRs / Monitoring
oral Retinoid

A
  • *PREGNANCY CATEGORY X**
  • unless using BC & willing to continue 3 years after treatment*
  • *Avoid ALCOHOL**
  • *during** & for 2 months after DC

Monitor:
TG’s & Liver Chemistry

ADR:

  • *Opthalmic** - photosensitivity / color vision / night vision
  • *GI** - hepatitis / jaundice / liver enzyme elevation
  • *Common**: HIGH TG’s / dry mouth/eyes/lips / brittle nails / alopecia
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5
Q

TOPICAL RETINOIDS
Tazarotine 0.1% & 0.05% cream/gel

ADR’s

A

HIGH incidence of irritation @ Application Site
DOSE DEPENDENT
causes : burning / stinging / itching / erythema

  • can be MINIMIZED by using:*
  • *creme formulation / alternate day app**
  • LIMIT treatment to 30-60 min*
  • *use moisturizers**

can be used in combo with topical corticosteroids

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6
Q

Biologic Response Modifiers = BRMs

Psoriasis Indications

Contraindications / Risks

A

Considered for patients with:
Moderate - Severe Psoriasis
when Other systemic agents are
INADEQUATE or CONTRAINDICATED

Immunomodulatory effects cause an:

  • *Increased Risk of INFECTION**
  • *Sepsis / TB reactivation / Opportunistic Infections**

NO LIVE VACCINES

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7
Q

Cyclosporine
ADR / Monitoring

A

Short Term Therapy <12weeks
Due to NEPHROtoxicity
Monitor
baseline BP, Scr, serum urea nitrogen, TG, CBC, uric acid, K, Mg should be taken, and rechecked every 2 weeks for first 12 weeks and monitored monthly after

AE:
renal toxicity, hypertension, hypertriglyceridemia (reversible upon discontinuation), hirsutism, risk of non- melanoma skin cancers increases with duration of treatment

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8
Q

Which PSORIASIS Drug?

Useful for patients with:
Moderate-Severe inverse psoriasis
VVV
affects INTERTRIGINOUS AREAS or FACE

A
  • *TOPICAL CALCINEURIN INHIBITORS = CNI**
  • *Pimecrolimus 1% cream (elidel) // Tacrolimus 0.1%**

LESS irritating vs Calcipotriol

  • *&**
  • AVOIDS* steroid ADR’s like skin atrophy
  • but steroids still may be more effective*

BBW = link between lymphoma & skin cancer

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9
Q

HIGHEST Potency Topical Steroid
for Psoriasis

Indications / Drug

A

indicated for:
VERY THICK PLAQUES
Plaques on:
PALMS or SOLES

BETAMETHASONE 0.5%

CLOBETASOL 0.05%

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10
Q

Topical CorticoSteroid ADRs

Psoriasis

A

Cutaneous ADRs
skin atrophy / acne / dermatitis / folliculitus
hypopigmentation / striai

Systemic ADRs
super potent // WIDE-SPREAD use of mid-potency agents
HPA axis suppression / cushings syndrome
Osteonecrosis / cataracts / glaucoma

TachyPhylaxis with prolonged use

Pregnancy CAT C

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11
Q

Which PSORIASIS DRUG is a:
CYP3A4 SUBSTRATE?

A

CYCLOSPORINE

Inhibitors –> INCREASE CSA concentration
veramapil / diltiazem / amiodarone / macrobide abx
allopurinol / SSRI / antifungals / CIPRO / grapefruit

Inducers –> decrease CSA conc.
anticonvulsnats / phenytoin / phenobarbital
rifAMPin / st johns / efavirenz

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12
Q

NON-Pharmacological Therapy

Psoriasis

A

Recommended THROUGHOUT ALL TREATMENT
along with anything else

STRESS reduction strategies

Moisturizers // Oatmeal Baths

  • *SPF 30**
  • *Skin Protection**

AVOID HARSH SOAPS // Detergents

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13
Q

Cyclosporine

Dosing Considerations

A
  • *Calcineurin Inhibitor**
  • blocks lymphocytes*

Dose should be:
Titrated to LOWEST effective dose for maintanence
to PREVENT RELAPSE

For DISCONTINUATION:
decrease dose 1mg/kg/day each week to prolong relapse
to avoid REBOUND PSORIASIS

  • *Short Term Therapy <12weeks**
  • reduce risk for nephrotoxcity*
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14
Q

MTX
Risk Factors for Hepatotoxcity

A

If they have these RISK FACTORS:
Consider LIVER BIOPSY
or if they have
MTX cumulative dose of 3.5-4g,

Hepatotoxicity Risk Factors:
H/O of moderate alcohol consumption
persistantly abnormal liver chem
history of liver disease = Hep B/C
FamHistory of liver disease
diabetes / Obesity / no FOLATE while on MTX

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15
Q

What is the MoA of these BRMs for Psoriasis?

Ustekinumab = Stelara

A

IL-12 / IL-23
inhibitor

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16
Q

Other Types of Psoriasis

except of PLAQUE psoriasis

A

Gluttate
small DOT like lesions = 2nd most common

  • *Pustular**
  • NOT infectious, pus has WBC*

Inverse
in SKIN FOLDS –> obese people

Erythrodermic
VERY SEVERE –> entire body / painful / temperature

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17
Q

Topical Vitamin D Analogs

ADRs

A

Cutaneous
Mild Irritant Contact dermatitis
others:
burning / pruritis / edema / itching / peeling /dryness

SYSTEMIC:
HYPERcalcemia // PTH SUPRESSION
rare unless using >5mg calcipotriol

Pregnancy Category C

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18
Q

Lower Potency Topical Steroid
for Psoriasis

Indications / Drug

A

indicated for:
INFANTS
face / interriginous / thin skin

HYDROCORTISONE 1%

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19
Q

Anthralin

Indication / ADR

A

Psoriasis Treatment
typically with UVB Phototherapy

Short Contact Athralin Therapy = SCAT
is preferred, AAA for 2 hours –> wipe off

  • not commonly used*
  • risk of* severe skin irritation
  • do NOT use on FACE or Intertriginous areas*
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20
Q

Which TOPICAL PSORIASIS DRUG

has a BLACK BOX WARNING?

  • possible link between the drug and:*
  • *lymphoma & skin cancer**
A

CALCINEURIN INHIBITORS

Pimecrolimus 1% (Elidel)

Tacrolimus 0.1%

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21
Q

INFLECTRA
is a Biosimilar to BRM?

A

INFLIXIMAB = Remicade

TNF-a inhibitor

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22
Q

Phototherapy

UVB

Indications / Treatments

A

for Moderate - Severe Psoriasis

Narrowband UVB or Broadband UVB
given with:
Crude Coal Tar or Anthralin
for enhanced efficacy

LASER treatment has HIGHER UVB dose = FASTER results

Contraindicated in patients with
history of melanoma or multiple nonmelanoma skin cancers

23
Q

Which PSORIASIS drug
can NOT be used with
UVB LIGHT PHOTOTHERAPY

A
  • *TOPICAL SALICYLIC ACID**
  • *keratoytic properties –> SCALP PSORIASIS**

may reduce EFFICACY
when used with UVB light phototherapy

24
Q

BRMs

Monitoring / Screening

A

BBW = Fatal Infections / Malignancies

Monitoring:
TB Testing // ANC
Baseline LFT & periodically
H/o or signs of Malignancy
COPD / CHF / GI perforation

25
Q

Which PSORIASIS drug?

MoA:
Binds to receptors, which results in
inhibition of KERATINOCYTE proliferation
&
enhancement of KERATINOCYTE differentiation

Inhibits T-lymphocyte Activity

A

TOPICAL VITAMIN D ANALOGS

Calcipotriol / CalcipoTriene
cream / solution / ointment foam

  • *Calcitriol Ointment**
  • for sensistive skin / skin folds*
26
Q
  • *Which PSORIASIS drug is
  • INACTIVATED by UV-A LIGHT?***
A

TOPICAL VITAMIN D ANALOGS

Calcipotriol / CalcipoTriene / Calcitriol Ointment

Apply AFTER UVA light exposure

27
Q

Which SYSTEMIC THERAPY of PSORIASIS

is the GOLD STANDARD?

and when is there an EXCEPTION?

A

METHOTREXATE
is gold standard

SAFER alternative to CSA
unless PRE-EXISTING LIVER DISEASE

28
Q

Which Psoriasis Drug?

Keratolytic Properties

Used in various:

  • *shampoo / bath oil formulations** for patients with:
  • *SCALP PSORIASIS**
A

TOPICAL SALYCYLIC ACID

Typically used in:
COmbination w/ topical corticosteroids
VVV
ENHANCES steroid penetration –> increase efficacy

CAN BE USED IN PREGNANCY
BUT:
AVOID in CHILDREN
also Systemic Absorption with 20% BSA & RENAL IMPAIRMENT

29
Q

Which PSORIASIS Drug?
Indication?

  • *PHOSPHODIESTERASE-4 INHIBITOR​
  • reduces* production of CYTOKINES**
A

APREMILAST = Otezla

Indicated for treatment of:
Moderate - Severe Plaque Psoriasis
for those who are
candidates for phototherapy or systemic therapy

30
Q

What is the MoA of these BRMs for Psoriasis?

Etnercept = Enbril

Certolizumab Pegol = Cimzia

A

TNF-a Inhibitor

Also:

Adalimumab = Humira

Infliximab = Remicade IV

31
Q

What is the MoA of these BRMs for Psoriasis?

Secukinumab = Cosentyx

Brodalumab = Siliq

Ixekizumab = Talz

A

IL-17
inhibitor

32
Q

Which Psoriasis DRUG?

MoA:
Normalizes abnormal keratinocyte differentiation

diminishes keratinocyte HYPERproliferation

CLEARS inflammatory infiltrate in psoriatic plaque

A

TOPICAL RETINOIDS
Tazarotine 0.1% & 0.05% cream/gel
ONCE DAILY

CATEGORY X

Effective in:
CLEARING psoriatic plaque Lesions
&
Achieving REMISSION

33
Q
  • *Genetic Factors:**
  • *Psoriasis**
A

Family History

PSORs1
on chromosome 6p is KEY gene –> 50% of heritability

Major Psoriasis Susceptibility genes:

  • *HLA**
  • *Cw6 TNF-a Interleukin-23**
34
Q

Pharmacologic Therapy for Psoriasis

Mild-Moderate Severity

A

TOPICAL TREATMENTS
are std of care

CorticoSteroids

Vitamin D Analogs

Retinoids

Salycylic Acid

Calcineurin Inhibitors = CNI

35
Q

Phototherapy

UVA

Indications / Treatments

A

for Moderate - Severe Psoriasis

  • *P+UVA**
  • *Psoralens** = Photosensitizer to ENHANCE efficacy

MOST EFFICACIOUS PHOTOTHERAPY TREATMENT

_topical VITAMIN D analogs
are INACTIVATED by UVA light_

Contraindicated in patients with
history of melanoma or multiple nonmelanoma skin cancers

36
Q

MTX
Monitoring for those WITHOUT hepatoxicity Risk factors

Hepatotoxicity Risk Factors:
H/O of moderate alcohol consumption
persistantly abnormal liver chem
history of liver disease = Hep B/C
FamHistory of liver disease
diabetes / Obesity / no FOLATE while on MTX

A

Patients W/O hepatotoxic risk factors

Liver Chemistry check every 1-3 months

Still:
consider LIVER BIOPSY if 5/9 AST levels
are ELEVATED over course of 12 months

37
Q

Which PSORIASIS drug is considered the
Safest LONG-TERM topical treatment?

A
  • *Topical VITAMIN-D Analogs**
  • *Calcipotriol** = cream / solution / ointment / foam
  • *Calcitriol OINTMENT**
  • less irritation in* sensitive skin areas = skin folds

Can be used in COMBINATION w/ topical steroid
more effective with comination
more expensive though

38
Q

Which PSORIASIS drug?

Direct anti-inflammatory benifits
due to its effects on
T-Cell Gene Expression & cytotoxic Effects
blocks DIHYDROFOLATE REDUCTASE

Inhibits FOLATE Synthesis

A

METHOTREXATE

Gold Standard for Psoriasis
safer alternative vs CSA, unless pre-existing liver disease

Pregnancy Catagory X

39
Q

Which SYSTEMIC THERAPY of PSORIASIS?

Active metabolite of:
aetretinate, Vitamin A acid derivative, oral retinoid

As MONOtherapy, initial response may be MORE rapid than MTX
In patients with SEVERE inflammatory psoriasis
low dose (25mg/day) is not recommended as monotherapy

Commonly used in COMBO w/ PHOTOTHERAPY

A

ACRETIN

Oral Retinoid

Moderate-Severe Psoriasis

often WITH PHOTOTHERAPY

40
Q

Which DRUG THERAPY for Psoriasis?

Anti-Inflammatory // Antiproliferative
Immunosuppresive / Vasoconstrictive
mech:
binds to intracellular corticoid receptors
&
regulates gene transcription

A

TOPICAL CORTICOSTEROIDS

Ointmets –> ENHANCE drug penetration
& have the most potent formulations
patients might prefer lotion/cream for daytime use

3 Levels of Potency

41
Q

Epidemiology / Etiology
Psoriasis

A

Male = Female

  • *Two Peaks**:
  • *20-30** & 50-60 y/o

T-lymphocyte-mediated systemic inflammatory disease

Epidermal HYPERplasia & Dermal Inflammation

Caused by:
Genetic & Environmental Influences

42
Q

Apremilast = Otezla

Dosing / ADR

A

PHOSPHODIESTERASE-4 INHIBITOR

Gradually INCREASE dose over 5 days
until
Dose of 30mg BID

for SEVERE renal impairment –> 30mg QD

ADR:
DIARRHEA - shortterm initial Treatment // Nausea / headache

43
Q

Mid-High Potency Topical Steroid
for Psoriasis

Indications / Drug

A

indicated for:
ADULTS
+ other areas of the body
NOT face / interriginous / thin skin

CLOBETASOL 0.05%
for scalp - foam / shampoo / spray

Spray / Foams = patient preferred, but higher cost

44
Q

Comorbidities with Psoriasis

A

Patients with Psoriasis have significant associated comorbidities:
Psoriatic Arthritis=PsA

  • *Metabolic Syndrome:**
  • *3x** more likely to have MI or STROKE
  • *5x** more likely to develop Diabetes

Crohn’s Disease / MS / T-cell lymphoma

  • *Psychiological Illnesses**
  • *ANX / Depression / Alcoholism**
45
Q

Clinical Presentation of
PLAQUE PSORIASIS

A

Appear on:
Scalp / Knees / Elbows / Lower Back

NAIL INVOLVEMENT
50% have fingernail / 35% have toenail

30% of patients have PsA = Psoriatic Arthritis
90% of patients with Psa have Nail involvement

46
Q

Systemic Therapies

Indication

A
  • *Mainstay of treatment for**
  • *Moderate - Severe Psoriasis**
  • topical therapies are adjuncts*

Traditional Agents:
Acetretin / Cyclosporine / MTX

NEWER AGENTS:

  • *Phosphodiesterase-4 Inhibitor**
  • *BRM Biologic Response Modifer Agents -Injectables**
47
Q

Appropriate Use of TOPICAL STEROIDS

for Psoriasis

A
  • *Potency Class 1**
  • LIMIT* duration to 2-4 weeks due to risk of:
  • *cutaneous / systemic ADRs**

Frequency of use should be gradually reduced once
clinical response is seen = TAPE

BID application is common

Pule Dosing also

48
Q

Environmental Risk Factors
Psoriasis

Drugs as well

A

Drugs that exacerbate pre-existing psoriasis:
Lithium / NSAIDs / Chloroquine
B-adrenergic blockers / Fluoxetine / CORTICOSTEROID withdrawal

INFECTION / Injury to Skin

OBESITY / STRESS

49
Q

Methotrexate

Drug Interactions / ADR

A

Pregnacy Category X

DI due to ALBUMIN binding:
Salicylates / phenytoin / trimethoprim / ciprofloxacin / thiazides

DI from Acidic Drugs:
Salicylates or VITAMIN C –> INCREASE MTX

ADR:
liver toxicity / nausea / pulmonary toxicity / pancytopenia

50
Q

Coal Tar

Indication / ADR

A

Psoriasis Treatment
typically with UVB Phototherapy

Can be helpful as a:
Adjunct w/ TOPICAL CORTICOSTEROIDS

  • LIMITED EFFICACY*
  • *WITHOUT PRESCRIPTION** as a:
  • *shampoo / cream / lotion / oil / oinmetn**
51
Q

Classification of

MODERATE - SEVERE

Plaque Psoriasis

A

NO LAB TEST FOR PSORIASIS

>5 - 10% of BSA

52
Q

What is the MoA of these BRMs for Psoriasis?

Tildrakizumab = Ilumya

Guselkumab = Tremfya

A

IL-23
inhibitor

53
Q

ELREZI
is a Biosimilar to BRM?

A

Enbrel = Etanercept
Also starts with E

TNF-a inhibitor

PDAT4 (34 decks)

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