Paradigm Shifts in the Management of Plaque Psoriasis: Advanced Practice Provider Perspectives - Episode 6

Nonbiologic Oral Systemics for Plaque Psoriasis

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Matthew Brunner, MHS, PA-C, DFAAPA, and Lakshi Aldredge, MSN, ANP-BC, DCNP, review use of nonbiologic oral systemic agents (eg, apremilast, methotrexate, acitretin) in the management of plaque psoriasis.


Matthew Brunner, MHS, PA-C, DFAAPA: Now we will transition to talking about some of the nonbiologic oral systemics. These consist of agents like apremilast and methotrexate. How do those get used in your practice, Lakshi?

Lakshi Aldredge, MSN, ANP-BC, DCNP: We're lucky to have more than one oral agent that we can use for psoriasis. Again, when we look at the gamut for treating psoriasis, we have topicals. We haven’t mentioned phototherapy, which we use somewhat in patients who have full-body psoriasis or [psoriatic plaques] just on their hands and feet. Narrowband UV-B therapy is used less often; now that we have systemic treatments that work, phototherapy is being used less and less.

Oral agents are great bridge drugs to use when going from topicals to systemic treatments. Sometimes, they can be used even after or in conjunction with the biologic agent. First, let me talk about methotrexate, an immunomodulator that has been around literally for decades. It is used in a lot of autoimmune conditions, including rheumatoid arthritis, psoriatic arthritis, and psoriasis. We even use it in certain cancers. It comes in 2.5 mg tablets, and it also can be injected subcutaneously. It helps modulate the immune system. In psoriasis, the immune system ramps up and produces more inflammatory cytokines, or proteins, that cause hyperproliferation or overproduction of keratinocytes in the skin and result in those big, thick plaques. Methotrexate normalizes, or calms down, the immune system to a healthier level. Methotrexate is taken once a week. We start with a very low dose, usually anywhere from 5 to 10 mg once a week. We monitor liver function and the complete blood count. Methotrexate is slow-acting. I tell my patients, “Don't expect an immediate response.” It sometimes takes months to see some improvement; as patients improve or don't improve, you can increase the dosage slowly. If you give them 3 to 6 months of treatment and it's not helping at a higher dose, then you need to switch them to something else. Methotrexate is designated as pregnancy category X, so it's not a great option for young women of childbearing age. Even with young males, ask about family planning before you prescribe methotrexate, and ask them about any history of hepatitis or liver disease. Also, counsel patients to limit their alcohol intake and use of any other medications that might have an impact on their liver.

Apremilast, a second oral agent that has been around since about 2008, has been a great addition to our oral armamentarium for treating psoriasis. Apremilast is a PDE4 [phosphodiesterase 4] inhibitor, so it works in a different way than methotrexate. We don't fully understand exactly how it impacts the skin, but we know that it helps decrease levels of inflammatory cytokines and increase levels of anti-inflammatory cytokines that help send the message to the skin to quit overproducing skin cells. Apremilast is given orally twice a day. You start at a low dose and slowly increase the dosage. We counsel our patients to monitor for mood changes. It's important to ask patients if they have a history of depression or suicidality. Matt, you mentioned that some our patients with psoriasis already have that as an underlying comorbidity. The most common complaint with patients who are on apremilast is stomach upset, diarrhea, nausea, and vomiting. That gets better over time, but you want to warn patients about that. Very rarely, you can see some weight loss; in your thinner, elderly patients, this may not be a great option. The one nice thing about apremilast is that there's no lab monitoring needed. That's nice for patients who don't want to come in frequently to have their blood tested.

A third oral medication option is acitretin. Again, it is used less frequently, but I typically use acitretin in my patients with palmar pustular psoriasis on their hands and feet. That's a specific variant of psoriasis, and I sometimes use that with narrowband UV-B therapy. It can be very effective in patients who have that specific subtype.

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Transcript edited for clarity.