PsA - Block 1 Flashcards
What are the triggers of psoriasis?
- Stress
- Seasonal changes
- Medications
What medications can induce psoriasis?
- NSAIDs
- Anti-malarial/ACEI
- Inderal (B-blockers)
- Lithium
- Steroid withdrawal/SSRI
Lesion sx of plaque psoriasis?
- Clearly distinguished from normal skin
- Covered by silver, flaking scales
* Auspitz sign: Removal accompanied by fine points of bleeding - Koebner phenomenon: May develop at sites of trauma or injury
Skin sx of plaque psoriasis?
Mild psoriasis — defined as ≤ 3% BSA involvement
Moderate psoriasis — defined as 3 – 10% BSA or PASI ≥ 8
Severe psoriasis — “Rule of 10”
* BSA ≥ 10%
* PASI ≥10
* DLQI ≥ 10
What are the concerns of having untreated psoriasis?
PsA
What is psoriatic diagnosis based on? Classifications
Recognition of characterisitc psoriatic lesions
Mild, moderate, severe
What is the objective evaluation of the extent of psoriasis?
- BSA
- Psoriasis Area & Severity Index (PASI)
What is the estimation of BSA psoriatic involvement?
- Palm size = 1% BSA
- Head & neck involvement = 10% BSA
- Both upper limbs = 20% BSA
- Trunk involvement = 30% BSA
- Both lower limbs = 40% BSA
What are the tx for psoriasis?
Non-pharmacologic therapy -> used for all patients with psoriasis, regardless of disease severity
Pharmacologic therapy -> individualized to each patient
How is a therapy selected?
Based on disease severity, presence or absence of comorbidities, and other special considerations (i.e., patient preferences, cost, hepatic or renal dysfunction).
Tx for mild-moderate psoriasis?
Topical therapies -> 1st line recommendation
Tx for mod-severe dx?
Phototherapy and photochemotherapy
Extensive moderate to severe psorias tx?
- Use systemic therapies ± topical therapies
- Biologic agents
Tx for controlled psoriasis?
Least potent, least toxic med
What are the non-pharm tx for psoriasis?
- Stress reduction
- Skin moisturizers
- Oatmeal baths
- Skin protection
- Avoidance of harsh soaps and detergents
- Management of comorbidities (DLD, obesity, CVD)
What is the fingertip unit method?
1 FTU = 500mg
The selection of TCS formulation is based on what factors?
- Assessment of dx severity
- Dx location
- Knowledge of patient preferences and age
- Cost/insurance converage
When would you use a lower potency TCS?
Infants and psoriatic lesions on face, intertriginous areas, or areas of thin skin
When would you use mid-to-high potency TCS?
Initial therapy to use for other areas on body
When would you use highest potency TCS?
reserve use for patients with thick plaques or recalcitrant disease
Topical retinoids
CI
Pregnancy
Calcipotriol
Counseling
- Inactivated by ultraviolet A (UVA) light; apply after, NOT before UVA light exposure
- Inactivated by acidic substances (i.e., salicylic acid); avoid concomitant use
Topical Vitamin D3 Analogs
preferred regimen, when used in topical therapy?
Short-contact anthralin therapy (SCAT)
Phototherapy & Photochemotherapy
Types, CI
Types:
* UV-A: PUVA
* narrow band UV-B: preferred (administered with coal tar (Goeckerman regimen) or anthralin (Ingram regimen)
CI: patients with history of melanoma or multiple non-melanoma skin cancers
Salicylic acid
Counseling
- Do NOT combine with ultraviolet B (UVB) phototherapy, as its filtering effect reduces UVB efficacy!
- Do NOT use with calcipotriol, as it inactivates the vitamin D3 analog!
Acitretin
CI, Warning, ADR, Monitoring
CI: Pregnancy, Methotrexate, Tetracyclines
Warnings: Depression, photosensitivity, pseudotumor cerebri
ADR: mucocutaneous effects
Monitoring: pregnancy testing
Counseling: Acitretin should NOT be used for women of child-bearing age UNLESS
* Able/willing to use effective contraceptive during therapy duration (AND) at least 3 years after discontinuing the medication
* Obtain two (2) negative pregnancy tests before initiating therapy, once monthly during therapy, and every three (3) months for three (3) years after discontinuing therapy
* Avoid use of alcohol during therapy and for two (2) months after discontinuing therapy
Cyclosporine
CI, ADR, Counseling
CI: Uncontrolled HTN
ADR: nephrotoxicity, hypertension, hypertriglyceridemia, hyperkalemia
Counseling: Do NOT administer with live vaccines
Methotrexate
CI, Counseling
CI: pregancy, lacation
Counseling:
* Foilic acid supplementation
* Screen high-risk patients for Hepatitis B and C before starting therapy.
* Patients should use effective birth control for 3 months (males) and one (1) ovulatory cycle (females) after discontinuing therapy
Tofacitinib
BBW, Warning, ADR, Monitoring, Counseling
BBW: ≥ 50 years old with ≥ 1 CV risk factor treated at higher doses
Warning: Gi perforations
ADR: Elevated BP and lipids
Monitoring: Lipids, BP
Counseling: Off-label for plaque psoriasis
* Do NOT administer with biologic DMARDs, potent immunosuppressants, or live vaccines
* Use caution in Asian patients due to increased frequency of side effects
Apremilast
CI, Warning, ADR, Monitoring
CI: pregnancy, breastfeeding
Warning: : GI effects (nausea, vomiting, diarrhea), weight loss, neuropsychiatric effects (depression, suicidal ideation, mood changes)
ADR: severe nausea, vomiting & diarrhea, weight loss, depression, suicidal ideation
Monitoring: signs & symptoms of depression, mood changes, suicidal thoughts
Counseling:
* Take medication with or without food.
* Counsel patients that this medication should NOT be crushed, chewed, or split
* dose titration to minimize GI effects
* Requires titration is CrCl <30mL/min
Route of admin for TNF-a inhibitors?
Intravenous (IV) — infliximab
Subcutaneous (SC) — etanercept, adalimumab, certolizumab pegol
Dosing frequency of TNF-a inhibitors?
Etanercept — once weekly
Adalimumab — once every 2 weeks
Certolizumab — once every 2 weeks
Infliximab — once every 8 weeks
TNF-a inhibitors
Warning, Monitoring, CI
Warning: HF
Monitoring: Before therapy initiation: tuberculosis (TB) and hepatitis B screening
CI: Do NOT administer with other biologic DMARDs or live vaccines
For patients on infliximab therapy premidication?
antihistamines, acetaminophen, & corticosteroids to reduce risk of infusion reactions
IL-12/IL-23 inhibitors
Brands, Monitoring, CI
Stelara (ustekinumab)
Monitoring: screenings for hepatitis B, hepatitis C, TB, & HIV
CI: Do NOT administer with live vaccines
IL 17 Inhibitors
Brands, CI, Warning, Counseling
- Cosentyx (secukinumab)
- Taltz (ixekizumab)
- Siliq (brodalumab)
- Bimzelx (bimekizumab)
CI: Chrohn’s (brodalumab)
Warning suicidal ideation (brodalumab, bimekizumab)
Counseling: Do NOT administer with live vaccines
* Use caution when using IL-17 inhibitors for patients with history of inflammatory bowel disease
* Avoid use of brodalumab in patients with Crohn’s disease.
* Black box warning for suicidal ideation (brodalumab)
IL-23 inhibitors
Brand, Monitoring, Counseling
- Tremfya (guselkumab)
- Ilumya (tildrakizumab)
- Skyrizi (risankizumab)
Monitoring: screenings for hepatitis B, hepatitis C, TB & HIV
Counseling: Do NOT administer with live vaccines!
