Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives - Episode 8
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: Apremilast is a beautiful new option that has been around for the last 5 years or so, and it has provided an excellent resource for patients who can’t take a biologic agent; for example, individuals who don’t necessarily have insurance or those who might be undergoing chemotherapy. It could also be patients with a more serious condition that prevents them from being on a drug that could potentially make them more vulnerable to infections such as a TNF [tumor necrosis factor]–alpha inhibitor. It could also be those who may have predisposing Crohn disease, in which IL-17–targeted agents might not be an option. It could be for whatever reason; ongoing chemotherapy or a major gastrointestinal surgery, for example.
Melodie S. Young, MSN, A/GNP-C: It is sometimes their choice: a thirdof the US population is needle phobic.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: Exactly.
Melodie S. Young, MSN, A/GNP-C: Sometimes, you can’t go straight from “You have psoriasis” to “I’d like to start you on injections.” That freaks them out, but they might be more amenable to taking a pill, to using an oral agent. It is sometimes the provider’s choice that you would recommend it, and it is sometimes the patient’s choice.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: It’s also a great option. I’ve changed patients from biologic agents to apremilast. For example, if they suddenly have a diagnosis of cancer and are undergoing chemotherapy, their oncologist wants them off a biologic. It’s a lovely option to be able to put them on apremilast. There’s great efficacy with that drug. What are the potential adverse effects? Potential adverse effects include depression or mood changes, although I’ve seen little of that in my population [at the Veterans Affairs Portland Health Care System], which tends to have a high risk for anxiety, depression, and suicide. I haven’t seen it much.
The biggest concern people have and the biggest complaint I see is diarrhea or upset stomach. I also tell the patient that this is a real adverse effect of this drug, but it gets better over time. In fact, when they start out, it comes in a bubble pack, and they start at a low dose twice a day and titrate it up slowly. The symptoms of that are usually mild, but it’s something for them to think and know about, so they don’t come back to you and say, “I quit taking that because I had horrible diarrhea.” You can reassure them and say, “I expected that. That’s something we know about with this drug, but it usually gets better over time.” You can also, very rarely, see some weight loss. I asked for samples, but they wouldn’t give them to me.
Melodie S. Young, MSN, A/GNP-C: It’s always the guys whenever you tell them, “It’s the adverse effect of this medicine. It’s GI [gastrointestinal] distress, and we can help you figure that out and work through that and weight loss. We’ll monitor your mood.” Those are the 3 major things, and they always say, “Weight loss? Tell me about the weight loss.” It can happen, and it’s usually going to be somewhere between 15 and 20 pounds in patients. It’s the people who want to lose weight. There’s no rhyme or reason who gets the benefit of that. If you had a person who struggled to keep their weight on–those few people out there in the world who have that issue–maybe they’re an older female who’s 100 pounds, that would be the 1 situation where I’d be hesitant to select that agent. Generally, it has tolerability if you coach people through the expectations of what might be.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: The other lovely thing about it is that there’s no lab monitoring that’s required, so this is great for people who have a busy lifestyle or those who don’t have the ability to come to see you. During COVID-19 [coronavirus disease 2019], they were some of the easiest patients for me to manage because I could do a phone call with them, and I didn’t have to have them come in for any blood tests. The 1 thing some of my patients say is that it’s hard to remember to take it twice a day. I say, “Do you brush your teeth in the morning and in the evening?” or “What in your routine do you do regularly every morning and in the evening? Match it up with that or set your cell phone alarm.” It’s very well tolerated, and they do well.
Melodie S. Young, MSN, A/GNP-C: With apremilast, it has a couple of indications: This is for plaque top psoriasis in adults with moderate to severe disease, and it also can be effective in psoriatic arthritis. We also know that there are a lot of people out there who are using it in addition to other biologic agents.
You can’t use or don’t want to use methotrexate along with a biologic agent, and that can be because the skin is doing well on 1 agent and we need some help because we can’t get the joints under control, or there are other types of situations. It may be the case that the patient is taking a biologic for another disease, such as HS [hidradenitis suppurativa] or Crohn disease. You’re then going to add apremilast to try to help with psoriasis. That is all off-label, but we all know that this is being done. I’m sure you hear of that or have tried to get those as well. Can you even do that within the VA?
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: Absolutely. I have spoken to several patients. There are a handful of patients who are on a biologic plus apremilast. It’s lovely because it has some symbiotic efficacy with other autoimmune modulators to work with some specific patients. The patients with whom I love this combination are those who have liver disease. They may have hepatitis or liver cancer, or they may be on other medications that are potentially toxic.
Melodie S. Young, MSN, A/GNP-C: Or for patients who drink a lot.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: It’s lovely to be able to add apremilast, and I don’t know how I managed to get this approved, but I will have them on a biologic agent as well as apremilast. It’s beautiful because some of them don’t have to come in for any monitoring whatsoever. Some of the biologic agents don’t even require that after the initial TB [tuberculosis] testing. Apremilast is a wonderful option, not just as a primary treatment but because it can be added as a secondary treatment alongside something else as well.
Melodie S. Young, MSN, A/GNP-C: If we can do monotherapy and find 1 agent that will work on all the aspects of that patient’s psoriatic disease, then that’s great. If not, then you’re going to have to mix phototherapy or use topical agents, systematic agents, or biologic agents. If you’re going to have to do more than 1 thing, then we’re hopefully going to see that apremilast can be that extra option.
I can tell you that, in the other specialties that focus on immune-mediated disease like gastroenterology and rheumatology, the NPs [nurse practitioners] I talk to who work in those diseases hardly ever get to use monotherapy. They almost always have to have a secondary option. Yet in dermatology, it’s a struggle to get insurance coverage to use more than 1 thing in those most difficult cases that can be controlled with just 1 thing.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: I also wanted to mention that apremilast doesn’t have any contraindications except for patients with moderate to severe renal disease. You might want to ask about that. We lowered the dose with that, so that’s something to think about. The other drug interaction that is rare is with other similar agents: cyclosporine, for example. You don’t want to mix that with this drug as well.
Transcript Edited for Clarity