Psoriasis Flashcards
Psoriasis co-morbidities
Psoriatic arthritis Psych CV IBS MS Lymphoma
Psoriasis precipitating factors
genetics skin trauma cold stress infection beta-blockers
Psoriasis exacerbating factors
lithium NSAIDs beta-blockers corticosteroid withdrawal stress sunburn
treatment for psoriasis caused by keritinocyte turnover
vitamin D analogs
retinoids
treatment for psoriasis caused by abnormal immune response
BRMs and corticosteroids
treatment for psoriasis caused by dendritic cells
phototherapy
What is auspitz’s sign
small pinpoints of bleeding
Mild or limited psoriasis
< or = 5% BSA
Moderate psoriasis
PASI > or = 8
Severe psoriasis
PASI > or = 10
DLQI > or = 10
BSA > or = 10%
5 non-pharm treatments for psoriasis
stress reduction aviod irritants oatmeal baths skin protection moisturizers
1st line for mild-moderate psoriasis
topical agents
2nd line for mild-moderate psoriasis
topical agents + phototherapy
3rd line for mild-moderate psoriasis
topical agents + systemic agent
1st line for moderate-severe psoriasis
systemic agent (BRM if comorbidities exist) + / - topical agents or phototherapy
2nd line for moderate-severe psoriasis
More potent systemic or BRM + / - topical agent or phototherapy
3rd line for moderate-severe psoriasis
BRM (or a different BRM) +/- other agents
corticosteroids MOA
anti-inflammatory, antiproliferative, immunosuppressive and vasoconstrictive
corticosteroid dosing in psoriasis
thin layer once or twice daily
low potentcy corticosteroid
hydrocortisone 1% (Hytone)
mid potency corticosteroid
betamethasone valerate 1% (betnovate)
first line corticosteroid
mid potentcy
high potency corticosteroid
halobetasol 0.05% (ultravate)
betamethasone dipropionate 0.05% (Diprolene)
use for hydrocortisone 1%
face or flexures
use for halobetasol 0.05%
short term only
use for betamethasone dipropionate
first line in thicker plaque areas (palms and soles)
systemic ADRs of corticosteroids
HPA suppression
osteonecrosis
cataracts
glaucoma
local ADRs of corticosteroids
striae skin atrophy acne contact dermatitis fungal skin infections rosacea
Corticosteroids preg Cat
C
Vitamin D analogs MOA
bind to Vit D receptors inhibit keratinocyte proliferation and enhance keratinocyte differentiation
vitamin D analogs dosing
5 mg/week
calcipotriene 0.005% brand name
dovonex cream, ointment, or solution
calipotriene dosing
AA BID up to 8 weeks
calcipotriene and betamethasone dipropionate brand name
taclonex cream, ointment or suspension
taclonex dosing
AA daily up to 4 weeks
AEs of vitamin D analogs
skin irritation erythema dryness stinging/burning hypercalcemia (high dose or CKD)
Vitamin D analogs Preg CAt
C
Time to response for vitamin D analogs
4-8 weeks
retinoids MOA
normalizes keratinocyte differentiation and has antiproliferative and antiinflammatory effects
tazarotene brand name
tazorac
tazarotene dosing
0.05% or 1% gel or cream daily
tazarotene AEs
skin irritation (erythema, pruritis, burning)
tazarotene preg Cat
X
Topical calcineurin inhibitors MOA
local immune modulating effects (blockage of cytokines) that normalizes hyperproliferation
topical calcineurin inhibitors dosing
twice daily
tacrolimus 0.03% and 0.1% brand name
protopic ointment
pimecrolumus 1% brand name
elidel cream
AEs of topical calcineurin inhibitors
HA fever skin burning pruritis erythema
topical calcineurin inhibitors BBW
malignancy
topical calcineurin inhibitors Preg Cat
C
type of light for phototherapy
UVA or UVB
type of light combined with psoralens
UVA
AEs of phototherapy
photosensitivity skin irritation cataracts photo aging lesional blistering
Acitretin brand name
Soriatane
acitretin dosing
10-50 mg once daily
What drug is synergistic with phototherapy
acitretin (reduce UV by 30-50%)
acitretin AEs
mucocutaneous dryness
hypervitaminosis A
hyperlipidemia
diffuse idiopathic skeletal hyperostosis
Acitretin BBW
blood donation x 3 years
alcohol use x 2 months
Acretin Preg Cat
X for 3 years after d/c
Acitretin drug interactions
Vitamin A
Cyp metabolism
Acitretin monitoring
Lipids/LFTs, preg test
Methotrexate MOA
anti-inflammatory effecs due to T-cell gene expression and cytostatic effects
Methotrexate dosing
2.5-5 mg /week up to 7.5-25 mg/week
Common AEs of methotrexate
N/V
mucosal ulceration
HA
anemia
Serious AEs of methotrexate
hepatotoxicity
pulmonary fibrosis
bone marrow suppression
CIs to methotrexate
pregnancy, unreliable birth control, renal impairment, hepatitis, cirrhosis, alcoholics, leukemia, thrombocytopenia
methotrexate pregnancy cat
X
methotrexate protein binding interactions
salicylates sulfonamides phenytoin thiazides cipro
methotrexate renal excretion interactions
salicylates
probenacid
ascorbic acid
Monitoring for methotrexate for no hepatic risk factors
liver biopsy with cumulative doses of 1.5 g
LFTs q 3 months
hepatic risk factors for methotrexate
history of EtOH> moderate persistant abnormal LFTs history of liver disease family history of liver disease obesity renal insufficiency advanced age hypoalbuminuria hepatotoxic meds
monitoring for methotrexate with hepatic risk factors
liver biopsy at baseline or 2-6 months
every time cumulative dose is 1-1.5 g
LFTs more frequently
monitoring for all methotrexate
CBC 7-14 days q2-4 weeks for first few months q1-3 months Renal function q 2-3 months pulmonary toxicity testing pregnancy test
cyclosporine MOA
inhibition of the production and release of IL2 and inhibits IL2 activation of resting T cells
cyclosporine dosing
2-2.5 mg/kg/day PO in 2 doses
max 5 mg/kg/day
short term 12 weeks to 1 year
AEs of cyclosporine
impaired renal function HTN hypertriglyceridemia hypomagnesemia hyperuricemia hypertrichosis
CIs to cyclosporine
abnormal renal function uncontrolled HTN malignancy prior PUVA uncontrolled infection immunodeficiency - not autoimmune
cyclosporine preg cat
C
monitoring for cyclosporine
BP + SCr baseline, biweekly for 12 weeks, qmonth
increase of 25%+ on 2 occassions decrease dose 25-50% -> still above 10% in a month d/c
Cyclosporine drug interactions
3A4 (grapefruit juice)
alefacept brand name
amevive
alefacept MOA
inhibits t-cell activation by targeting CD2 and inducing apoptosis of memory cells
alefacept preg cat
B
alefacept dose
15 mg IM QW x 12
alefacept BBW
malignancy
alefacept AEs
lymphopenia myalgias chills pharyngitis cough nausea injection site reaction
alefacept monitoring
CD4 T cell count biweekly
< 250 hold dose
<250 x 4 weeks d/c
TNF alpha inhibitors used for psoriasis
etanercept
infliximab
adalimumab
TNF alpha inhibitor MOA
binds and inactivates TNF alpha preventing interaction with its cell surface receptors
BBW of TNF alpha inhibitors
serious infections
malignancies
TNF inhibitors monitoring
PPD yearly, periodic CBC + LFTs
Etanercept brand name
enbrel
infliximab brand name
remicade
adalimumab brand name
humira
etanercept dosing
50 mg SQ twice weekly x 12 weeks
50 mg SQ qweek
etanercept AEs
injection site reaction HA URI GI upset Hep B reactivation worsening/new onset CHF
infliximab dosing
5 mg/kg IV over 2-3 hours at 0,2,6 weeks then q 8 weeks
infliximab AEs
hemolytic abnormalities hepatotoxicity hypersensitivity ocular toxicity worsening/new onset CHF
adalimumab dosing
80 mg SQ week 1
40 mg SQ week 2, q 2weeks
adalimumab AEs
Hemolytic abnormalities
injection site reaction - pruritic urticarial rash
ustekinumab brand name
stelara
ustekinumab MOA
binds to and interferes with IL12 and IL13 preventing activation of t cells
ustekinumab dosing
< or = 100 kg 45 mg SQ at weeks 0,4,q12 weeks
>100 kg 90 mg SQ at weeks 0,4 q 12 weeks
AEs of ustekinumab
URI HA tiredness serious infections malignancies reversible posterior leukoencephalopathy syndrome
secukinumab brand name
cosentyx
secukinumab MOA
binds to and interferes with IL-17a preventing activation of t-cells
secukinumab dosing
300 mg SQ weeks 0,1,2,3,4
300 mg SQ q 4 weeks
secukinumab AEs
infection
URI
apremilast brand name
Otezla
apremilast MOA
inhibits PDE4 which results in increased cAMP and decreased inflammatory feeling (NO, TNFa, IL23, IL10)
apremilast dosing
10 mg AM day 1 titrating to 30 mg BID by day 6
apremilast AEs
HA fatigue weight loss diarrhea nausea
