Psoriasis Treatment

Question 1

what are the indications for biologic treatment?

Answer 1

Patients with moderate to severe psoriasis

• Patients with psoriatic arthritis, particularly those who have failed other disease-modifying antirheumatic drugs (DMARDs)

NOTE : Guttate, pustular, or erythrodermic psoriasis are not established indications, but there is anecdotal evidence for efficacy and safety.

Question 2

Yalla! absolute Contraindications for Biologic therapy ?

Answer 2

Significant viral, bacterial, or fungal infection, including active Salmonella or dimorphic fungal infection

Increased risk for developing sepsis

Active tuberculosis

Allergic reaction to the biologic agent

Selective for TNF inhibitors: ANA+ (especially if high titer) or autoimmune
connective tissue disease, blood dyscrasias, congestive heart failure (NYHA grade III or IV), or demyelinization disorders (the latter also if in first-degree relative)

Question 3

Absolute contra indications specific for ANTI-TNF?

Answer 3

Selective for TNF inhibitors:
ANA+ (especially if high titer)

or autoimmune
connective tissue disease,

blood dyscrasias,

congestive heart failure (NYHA grade III or IV),

or demyelinization disorders (the latter also if in first-degree relative)

Question 4

CONTRAINDICATION FOR USTEKINOMAB ?

Answer 4

Selective for ustekinumab: BCG vaccination within the past 12 months (mode of action expected to increase susceptibility to mycobacterial infections)

Question 5

contraindications Selective for secukinumab, ixekizumab, and brodalumab ?

Answer 5

active Crohn disease (may cause exacerbation of bowel disease)

+ causes candidiasis FYI

Question 6

other contraindications for biologic therapy ?

Answer 6

• History of hepatitis B viral (HBV) infections:
  If HBsAg-positive, measure HBV DNA and treat with antiviral agent (e.g. tenofovir, entecavir, telbivudine) prior to immunosuppressive therapy.

Monitor for reactivation in those with anti-HBs or -HBc antibodies who are HBsAg-negative).

• History of hepatitis C viral infection (risk of activation) : Need to monitor liver function tests and viral load.
• Immunosuppressed patient
• Pregnancy (TNF inhibitors appear to be safe)
• Breastfeeding
• Malignancy within the past 5 years (does not include adequately treated
  cutaneous squamous or basal cell carcinoma)
• excessive chronic sun exposure or photo(chemo)therapy

Question 7

WHAT IS SPESOLIMAB AND WHAT IS IT USED FOR ?

Answer 7

SPESOLIMAB IS AN INTERLEUKIN 36 INHIBITOR INHIBITOR - RECENTLY APPROVED FOR GENERALIZED PUSTULAR PSORIASIS

Question 8

regarding the treatment with biologic therapy for psoriasis - name the other situations in which targeted immunomodulators become first-line therapy?

Answer 8

In addition to Moderate-Severe disease, biologics may be used in:

-Acute arthritis
- Severe Depression
- Suicidal ideation

Question 9

Give example of beneficial treatment combinations in psoriasis ?

Answer 9

• TOPICALLY

Calcipotriene + Potent topical corticosteroids.

• SYSTEMIC COMBINATIONS

MTX can be combined with Biologic therapies that can induce autoantibodies ( e.g adalimumab and infliximab)

Question 10

what about the combination of acitretin and cyclosporin ?

Answer 10

such combination carries the risk of accumulation of cyclosporin.

This happens due to the fact that acitretin is a cytochrome P450 inhibitor (P450 processes cyclosprine and inactivates this drug) which results in accumulation of Cyclosporine.

But rheumatologist use this combo, so do dermatologists in case of recalcitrant psoriasis.

Question 11

what about the combination of MTX and acitretin? in regards to psoriasis

Answer 11

This is a combo that is only used is patients that failed all other treatments.

Although very effective but it carries the risk of hepatotoxicity. thus careful monitoring is required

Question 12

what about PUVA and cyclosporine ?

Answer 12

If a patient has received PUVA therapy in the past, the use of cyclosporine should be avoided.

Question 13

Regarding Management of childhood psoriasis?

Answer 13

the therapy should be managed topically with the first line being TOPICAL CALCIPPOTREINE for mild-moderate juvenile psoriasis . it can be combined with corticosteroids (moderate severe).

regarding treatment resistant facial involvement\ flexural areas tacrolimus 0.1 % ointment can be added.

In some countries, anthralin is then considered if this treatment regimen is not effective or if the psoriasis is moderate to severe.

narowband UVB can be also considered especially if the patient is a young adult ( with attention to the number of treatment)

antiobiotics are controversial but can be used in guttate when strep infection is suspected

Question 14

when do you consider retinoids for psoriasis in children?

Answer 14

in pustular and erythrodermic pso

Question 15

what systemic meds are used for pediatric pso?

Answer 15

• MTX
• retinoids - erythrodermic and pustular
• Cyclosporine is occasionally utilized for exceptional cases.

IMMUNOMODULATORS AS WELL

Question 16

ARE IMMUNOMODULATORS USED IN CHILDHOOD PSORIASIS? IF SO FROM WHAT AGE

Answer 16

YES !! SOME ARE APROVED BY FDA ALREADY :)

• ETANERCEPT ( SAFE FROM AGE OF 4)

AND THE FOLLOWING ARE SAFE FROM AGE OF 6 :

• USTEKINUMAB (AKA STELARA - INHIBITOR OF P40 SUBUNIT OF IL12\IL23)
• SECUKINUMAB ( COSYNTEX - IL 17 INHIBITOR)
• IXEKIZUMAB ( TALTZ - IL17 INHIBITOR)

REGARDING THE EMA THEY ALSO APPROVED THE ABOVE BUT THE AGE FOR ETANERCEPT IS ABOVE THE AGE OF 6 AND NOT FROM 4.

ALSO EMA APROVED ADALIMUMAB

Question 17

A 60 year old patient with history of CHF and MS. comes to your office and mentions that recently she is ill and isnt feeling well in general, Dermatologically she states that her psoriasis is exacerbating and is interested in Adalimumab? what is the next step?

Answer 17

this patient suffers from comorbidities that are contraindicatinve for TNF inhibitors . ( MS, CHF) and also recently she seems to be ill and developing a recent infection,

all of which are contraindicative for TNF inhibitors ( adalimumab, etanercept, Infliximab, Cetrolizumab )

also Hep B infection is contraindicative but hep c is ok

Question 18

a psoriatic patient is interested in tremfya for psoriasis treatment. she says MTX doesnt “ do the job “ anymore and has some lesions that make her anxious and QOL is affected. during your assessment and preparation u discover latent TB ? what would you do ?

Answer 18

latent TB isnt contraindicative for IL23 or IL12/23 Inhibitors

:) so she can get it

Question 19

a patient with Hyperlipidemia, depression presents to the outpatient clinic with widespread psoriasis vulgaris is interested in IL17 inhibitors and IL17 receptor inhibitor as a therapy? please explain

Answer 19

this patient is eligible for IL17 inhibitors but not for IL17-R blockers due to the fact that he is suffering from depression

thus he can get :
-Secukinumab (IL7A inhibitor - cosyntx)
- Ixekizumab ( IL17A inhibitor Taltz)
-