Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives - Episode 7
Melodie S. Young, MSN, A/GNP-C: You mentioned pills, so we’re going to talk about systematic therapy a bit. Going back to my career in the late 1980s and early 1990s, we had methotrexate, then acitretin, which is a retinoid. Then cyclosporine hit the market. It’s still approved, but only for a year of utilization and for severe patients. A few years back, we had a new oral agent that came onto the market, and it’s been widely accepted by patients and the dermatology community as well. I want to mention that. What do you think about systematic agents? How often do you use them, and do patients have more interest in them? Let’s talk about systematic agents a bit.
I know methotrexate is widely used worldwide. I’ve used so much of it, but a lot of practices are not comfortable with it. You have to be careful, particularly in certain populations. There are drug-drug interactions, and if the patient drinks, has hepatitis or liver disease, or is older, it can be an issue. It has its utility, but it’s tricky. I definitely want to talk about apremilast and its safety, and then we’ll mention any of the other oral agents that have been out longer. Do you have any pros and cons of how to use those within your clinic [Veterans Affairs Portland Health Care System]?
Lakshi M. Aldredge, MSN, ANP-BC, DCNP:It’s important. Many of my veterans, which is the population I treat, have a lot of comorbidities. Methotrexate has been around for decades, and it’s a great drug. It has great utility in a lot of autoimmune conditions. What’s the downside of methotrexate? It can affect the liver, and it can affect the blood counts in some individuals. You have to know your patients. You have to know all their health history and all their medications. Methotrexate is a medication that is taken orally once a week. We give people folic acid as a vitamin to take with it on a daily basis to help absorb the methotrexate better and to prevent some of the adverse effects. What you want to watch for with methotrexate is that it’s an absolute contraindication in any individuals who are thinking about starting a family.
Melodie S. Young, MSN, A/GNP-C: For men or women, methotrexate should not be used.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: It’s not a good option, as well as acitretin.
Melodie S. Young, MSN, A/GNP-C: Correct. It’s a no-no.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP:Both are highly teratogenic, so they would be off the table to begin with. Other things to think about are the patient’s alcohol use because of that liver potential. With methotrexate, it’s also a slow onset; it’s the same with acitretin. You need to have them come in relatively often, every 2 to 3 months initially, for lab tests, so you can monitor their liver function and triglycerides with both methotrexate and acitretin. It has a slow onset, so this something that’s not going to give them rapid relief right away, and you start low and slow. You slowly titrate them up.
When is this a good drug to use? When patients who, unfortunately, do not have drug coverage or insurance, this might be 1 of the only options. It can also work well in the joints. Methotrexate is often used in the joints and oftentimes. Mel and I will add methotrexate to a patient who has a biologic agent where their skin is beautifully controlled, but they might have a bit of joint disease that is still bothersome. We might give them a bit of methotrexate to add to that. It works great. Methotrexate has its utility, but it’s not something I’m going to use as a first-line treatment in a young individual or perhaps even an older individual or for anybody who drinks, which is everybody now during COVID-19 [coronavirus disease 2019]. If they tell you they have 3 drinks a night, that means they really have 6. Ask me how I know. It can also be challenging because of the lab follow-up.
Melodie S. Young, MSN, A/GNP-C: I’m not a fan of systemic steroids for chronic disease period. They are the dirty little secret when we use them. We use them because we can give it to people, and they feel better for a while. You’re going to have hell to pay later, and you can have quite a significant rebound from it. It can turn mild psoriasis or moderate disease into an eruptive, disastrous disease from which they have to be rescued. I’m not a fan.
There is no good evidence, and if we’re going to promote evidence-based decision-making, you should look at the patient, look at the disease, and look at the drugs that are available that are FDA approved, and use those. I would be afraid if a person came in and had severe sinusitis or had a severe case of poison ivy and had psoriasis. I would be afraid for them to get systemic steroids because it can destabilize well-controlled, chronic skin disease if you use them. With the newer therapies we have now, whether it’s a systemic agent like apremilast or a biologic agent, I don’t have issues when a person has to have a systemic steroid for another reason. I’m not a fan.
That’s also risky legally because it is not part of the standards of care. It’s what is going to be recommended to do. For chronic diseases, you want to use as little as possible. There are cases when you have to because there are no FDA-approved drugs to treat certain conditions. To do it for psoriasis or atopic dermatitis, you’re putting yourself at risk, and you’re putting the patient at risk.
Transcript Edited for Clarity