Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents

Current investigational drugs in psoriasis

INTRODUCTION

The advent of biologic therapies has revolutionized the treatment of psoriasis. Increased understanding of immunogenetic pathways has allowed for the development of more selective targeted biologic therapies. Multiple new treatments are currently in development for the treatment of psoriasis. Preliminary data for many of these agents, particularly with regard to agents targeting the IL-23/Th17 pathway, are promising. Proven long-term safety, however, is an absolute necessity with newly developed drugs, and should, therefore, still be considered second-line agents to current established treatments with long-term safety data.

AREAS COVERED

This review details the mechanisms of action of drugs currently in development or in clinical trials for the treatment of psoriasis, using clinical trial registries and associated publications. Readers will gain a comprehensive overview about the mechanism of action of emerging treatments targeting various immune pathways deeply involved in psoriasis. Pathogenesis, clinical efficacy and safety data for these treatments are discussed where available.

EXPERT OPINION

Psoriasis remains a heavily undertreated systemic immune-mediated disease despite increased understanding of immunopathogenesis of the disease and advent of a multitude of novel therapeutic agents with potentially improved bioavailability and safety profiles. Limitations, however, remain in the realm of topical agents for treatment of mild to moderate psoriasis, which has seen little progress over the years. A concerted effort will need to be made among researchers, clinicians and patient advocacy groups to ensure new therapeutic agents are developed and gain proper exposure.

A randomized placebo-controlled trial of methotrexate in psoriatic arthritis

Objective. MTX is widely used to treat synovitis in PsA without supporting trial evidence. The aim of our study was to test the value of MTX in the first large randomized placebo-controlled trial (RCT) in PsA.

Methods. A 6-month double-blind RCT compared MTX (15 mg/week) with placebo in active PsA. The primary outcome was PsA response criteria (PsARC). Other outcomes included ACR20, DAS-28 and their individual components. Missing data were imputed using multiple imputation methods. Treatments were compared using logistic regression analysis (adjusted for age, sex, disease duration and, where appropriate, individual baseline scores).

Results. Four hundred and sixty-two patients were screened and 221 recruited. One hundred and nine patients received MTX and 112 received placebo. Forty-four patients were lost to follow-up (21 MTX, 23 placebo). Twenty-six patients discontinued treatment (14 MTX, 12 placebo). Comparing MTX with placebo in all randomized patients at 6 months showed no significant effect on PsARC [odds ratio (OR) 1.77, 95% CI 0.97, 3.23], ACR20 (OR 2.00, 95% CI 0.65, 6.22) or DAS-28 (OR 1.70, 95% CI 0.90, 3.17). There were also no significant treatment effects on tender and swollen joint counts, ESR, CRP, HAQ and pain. The only benefits of MTX were reductions in patient and assessor global scores and skin scores at 6 months (P = 0.03, P < 0.001 and P = 0.02, respectively). There were no unexpected adverse events.

Conclusions. This trial of active PsA found no evidence for MTX improving synovitis and consequently raises questions about its classification as a disease-modifying drug in PsA.

Trial registration. Current Controlled Trials, www.controlled-trials.com, ISRCTN:54376151.

Serum leptin, adiponectin, resistin and ghrelin levels in psoriatic patients treated with cyclosporin

Cyclosporin has various effects on adipose tissue and glucose metabolism. This situation may lead to changes in serum levels of adipocyte-derived cytokines which have influence on the pathogenesis of psoriasis. The aim of this study was to evaluate the effect of cyclosporin treatment on some adipocyte-derived cytokines in psoriatic patients. This case-control study was performed between June 2009 and March 2010, at the Department of Dermatology of Meram School of Medicine. Serum leptin, adiponectin, resistin and ghrelin levels were assessed in 26 patients with psoriasis before and after cyclosporin treatment and body mass index-matched 26 healthy control subjects. The adipokines levels were compared between the groups. Serum leptin, ghrelin, resistin and adiponectin levels in patients with psoriasis before the treatment were higher than those of the control group but the differences were not statistically significant. A positive correlation between serum leptin and family history of psoriasis was detected (r = 0.398, P = 0.044). A strong negative correlation between the Psoriasis Area and Severity Index and serum ghrelin levels was seen (r = -0.52, P = 0.001) and there was a strong positive correlation between the Nail Psoriasis Severity Index and serum resistin levels (r = 0.62, P = 0.001). Following the treatment, a significant increase was seen in the serum level of adiponectin (P = 0.02) and resistin (P = 0.003). The correlations between the adipokines and the disease parameters before the treatment were lost after the treatment. Our results suggest that levels of some adipocyte-derived cytokines in psoriatic patients are affected by cyclosporin treatment.

Apremilast mechanism of action and application to psoriasis and psoriatic arthritis

Psoriasis and psoriatic arthritis are common clinical conditions that negatively impact health-related quality of life and are linked to serious medical comorbidities. Disease mechanisms involve local and systemic chronic inflammatory processes. Available biologic therapies specifically target single inflammatory mediators, such as tumor necrosis factor-α (TNF-α), in the context of a larger inflammatory signaling cascade. To interrupt this pathological cascade earlier in the response or further upstream, and return pro-inflammatory and anti-inflammatory signaling to a homeostatic balance, the use of a phosphodiesterase4 (PDE4) inhibitor has been explored. PDE4 is the major enzyme class responsible for the hydrolysis of cyclic adenosine monophosphate (cAMP), an intracellular second messenger that controls a network of pro-inflammatory and anti-inflammatory mediators. With PDE4 inhibition, and the resulting increases in cAMP levels in immune and non-immune cell types, expression of a network of pro-inflammatory and anti-inflammatory mediators can be modulated. Apremilast is an orally available targeted PDE4 inhibitor that modulates a wide array of inflammatory mediators involved in psoriasis and psoriatic arthritis, including decreases in the expression of inducible nitric oxide synthase, TNF-α, and interleukin (IL)-23 and increases IL-10. In phase II studies of subjects with psoriasis and psoriatic arthritis, apremilast reversed features of the inflammatory pathophysiology in skin and joints and significantly reduces clinical symptoms. The use of an oral targeted PDE4 inhibitor for chronic inflammatory diseases, like psoriasis and psoriatic arthritis, represents a novel treatment approach that does not target any single mediator, but rather focuses on restoring a balance of pro-inflammatory and anti-inflammatory signals.

Patient preferences for psoriasis treatments: impact of treatment experience

BACKGROUND

Patient preferences for psoriasis treatments can impact treatment satisfaction and adherence and may therefore influence clinical outcome.

OBJECTIVE

To assess the impact of treatment experience (satisfaction with current treatment, number of prior visits, disease duration, number of preceding therapies and currently prescribed treatment modalities) on treatment preferences.

METHODS

A computer-based conjoint analysis experiment was conducted to analyse preferences of patients with moderate or severe psoriasis (n = 163) treated at a German University Medical Center for outcome (probability, magnitude and duration of benefit; probability, severity and reversibility of side effects) and process attributes (location, frequency, duration, delivery method, individual cost) of psoriasis treatments. Relative importance scores (RIS) were calculated for each attribute and compared using anova, post hoc test and multivariate regression analysis.

RESULTS

Participants with longer disease duration attached significantly greater importance to duration of benefit (β = 0.206, P = 0.018), whereas participants on oral therapy were more concerned about magnitude of benefit by trend (β = 0.218, P = 0.058). Participants receiving injectables not only set higher value to probability of benefit (RIS = 32.80 vs. 21.89, P = 0.025) but also to treatment location (RIS = 44.74 vs. 23.03, P = 0.011), delivery method (RIS = 43.75 vs. 19.29, P = 0.019), treatment frequency (RIS = 31.24 vs. 16.89, P = 0.005) and duration (RIS = 32.54 vs. 16.57, P = 0.003) when compared with others. Treatment satisfaction was significantly higher in participants on infusions or injections compared with those on phototherapy and mere topical therapy.

CONCLUSIONS

Treatment preferences may change over time course and with treatment experience. Participants on injectables attach great importance to efficiency and convenience of therapies, and are highly satisfied with their treatment.

Body surface area measurement and soft clustering for PASI area assessment

Psoriasis is a common skin disorder with a prevalence of 0.6 - 4.8% around the world. The most common is plaques psoriasis and it appears as red scaling plaques. Psoriasis is incurable but treatable in a long term treatment. Although PASI (Psoriasis Area and Severity Index) scoring is recognised as gold standard for psoriasis assessment, this method is still influenced by inter and intra-rater variation. An imaging and analysis system called α-PASI is developed to perform PASI scoring objectively. Percentage of lesion area to the body surface area is one of PASI parameter. In this paper, enhanced imaging methods are developed to improve the determination of body surface area (BSA) and lesion area. BSA determination method has been validated on medical mannequin. BSA accuracies obtained at four body regions are 97.80% (lower limb), 92.41% (trunk), 87.72% (upper limb), and 83.82% (head). By applying fuzzy c-means clustering algorithm, the membership functions of lesions area for PASI area scoring have been determined. Performance of scoring result has been tested with double assessment by α-PASI area algorithm on body region images from 46 patients. Kappa coefficients for α-PASI system are greater than or equal to 0.72 for all body regions (Head - 0.76, Upper limb - 0.81, Trunk - 0.85, Lower limb - 0.72). The overall kappa coefficient for the α-PASI area is 0.80 that can be categorised as substantial agreement. This shows that the α-PASI area system has a high reliability and can be used in psoriasis area assessment.

The Use of Methotrexate in Dermatology / Upotreba metotreksata u dermatologiji

Methotrexate is a cytotoxic antimetabolite agent and a folic acid antagonist. Except for its use in oncology and rheumatology, it is widely used in dermatology. The most important indications include severe forms of psoriasis, but also a wide range of autoimmune diseases and dermatoses with different etiology and pathophysiology such as: bullous pemphigoid, dermatomyositis, pityriasis rubra pilaris, sarcoidosis, T-cell lymphomas, Behcet’s disease, adult atopic eczema, scleroderma, Reiter’s syndrome and many others. For dermatological indications methotrexate is usually taken in low oral doses, 5-25 mg once a week. In certain diseases it can be applied to the lesion itself, or in the form of local preparations. Considering the fact that numerous drugs affect various metabolic phases of methotrexate and may increase its toxicity, it is of utmost importance to consider other prescribed drugs, especially certain antibiotics, nonsteroidal antiinflammatory drugs, antiepileptic drugs, retinoids, proton pump inhibitors and so on. If the selection of patients is correct, if drugs are taken regularly and laboratory monitoring is included, methotrexate is a truly efficient and safe drug that can be taken for months or years if necessary.

Alopecia areata developing paralell to improvement of psoriasis during ustekinumab therapy

BACKGROUND

Ustekinumab is a new immunosuppressive anti-psoriasis agent. The drug targets the p40 subunit of IL-12 and IL-23 and indirectly inhibits cytokine production by Th17 cells.

MAIN OBSERVATIONS

We present a case of a 36-year-old male patient with psoriasis, who received ustekinumab therapy, applied in 45mg subcutaneous injections at week 0, 4 and than every 12 weeks. After 7 months of therapy PASI decreased from 10,1 to 0,9. At this phase of therapy he developed two patches of alopecia areata on the scalp. The diagnosis was made based on clinical appearance and was confirmed by trichoscopy (hair and scalp dermoscopy) and reflectance confocal microscopy. The development of alopecia areata was preceded by emotional stress and dental infection.

CONCLUSIONS

Ustekinumab seems an unlikely cause of alopecia areata in this patient. However, lack of efficacy is preventing hair loss may indicate that interleukin- 12 cytokine family is not a key player in pathogenesis of alopecia areata.

A 52-week trial comparing briakinumab with methotrexate in patients with psoriasis

BACKGROUND

Briakinumab is a monoclonal antibody against the p40 molecule shared by interleukin-12 and interleukin-23, which is overexpressed in psoriatic skin lesions. We assessed the efficacy and safety of briakinumab as compared with methotrexate in patients with psoriasis.

METHODS

In this 52-week trial, we randomly assigned 317 patients with moderate-to-severe psoriasis to briakinumab, at a dose of 200 mg at weeks 0 and 4 and 100 mg at week 8 and every 4 weeks thereafter (154 patients), or methotrexate, at a dose of 5 to 25 mg weekly (163 patients). The primary end points were the percentages of patients with at least 75% improvement in the score on the psoriasis area-and-severity index (PASI) at weeks 24 and 52 and a score on the physician's global assessment of 0 (clear; i.e., no apparent disease) or 1 (minimal disease) at weeks 24 and 52. A total of 248 patients were enrolled in an ongoing 160-week open-label continuation study.

RESULTS

At week 24, a total of 81.8% of the patients in the briakinumab group versus 39.9% in the methotrexate group had at least 75% improvement in the PASI score, and 80.5% versus 34.4% had a score of 0 or 1 on the physician's global assessment. The corresponding percentages at week 52 were 66.2% versus 23.9% with at least a 75% improvement in the PASI score and 63.0% versus 20.2% with a score of 0 or 1 on the physician's global assessment (P<0.001 for all comparisons). During the 52-week study, serious adverse events occurred in 9.1% of the patients in the briakinumab group (12.9 events per 100 patient-years) and in 6.1% in the methotrexate group (10.6 events per 100 patient-years). Serious infections occurred in 2.6% of the patients in the briakinumab group (4.1 events per 100 patient-years) and in 1.8% in the methotrexate group (2.7 events per 100 patient-years); cancers occurred in 1.9% (2.0 events per 100 patient-years) versus 0%.

CONCLUSIONS

Briakinumab showed higher efficacy than methotrexate in patients with moderate-to-severe psoriasis. Serious infections and cancers occurred more frequently with briakinumab, but the differences were not significant. (Funded by Abbott Laboratories; ClinicalTrials.gov number, NCT00679731.).

The long-term safety of adalimumab treatment in moderate to severe psoriasis: a comprehensive analysis of all adalimumab exposure in all clinical trials

BACKGROUND

A favorable benefit-risk profile has been established for adalimumab, with up to 5 years of treatment in 13 clinical trials in patients with moderate to severe chronic plaque psoriasis.

OBJECTIVE

The aim of this analysis was to assess the long-term safety of all adalimumab exposure in all psoriasis clinical trials.

METHODS

A total of six sets of data were analyzed as follows: (i) all cumulative safety data from all exposure for all adalimumab-treated patients in the 13 clinical trials in moderate to severe psoriasis (All Adalimumab Treatment Population) through April 2007, November 2008, and November 2009, respectively; (ii) longitudinal data for 1403 patients treated with adalimumab 40 mg every other week (eow) dosing (Every Other Week Population) through June 2007 and April 2010; and (iii) data from placebo-controlled periods of clinical trials. Adverse events that occurred up to 70 days after the final dose of adalimumab were analyzed.

RESULTS

During placebo-controlled periods, a total of 572 patients had 173.0 patient-years (PYs) of exposure to placebo and 1188 patients had 370.5 PYs of exposure to adalimumab. Adverse event incidence rates, expressed as events per 100 PYs (events/100 PYs), for placebo- and adalimumab-treated patients for serious adverse events were 7.52 and 8.64, and for serious infectious adverse events were 2.89 and 2.43, respectively. In the 2007, 2008, and 2009 All Adalimumab Treatment Population there were, respectively, 1819 patients (2424.7 PYs), 2197 patients (4351.9 PYs), and 3010 patients (4844.7 PYs), with serious adverse event incidence rates of 6.51, 7.22, and 8.36 events/100 PYs, and serious infectious adverse event rates of 1.32, 1.38, and 1.65 events/100 PYs. In the 2007 and 2010 Every Other Week Population (n = 1403), there were 1883.5 and 2854.1 total PYs of exposure, respectively, with serious adverse event incidence rates of 6.32 and 6.87 events/100 PYs, and serious infectious adverse event rates of 1.33 and 1.37 events/100 PYs, respectively.

CONCLUSIONS

Multiple lines of evidence from a total of six sets of safety data, with treatment for up to 5 years, including results from all adalimumab-treated patients, and a subset of patients treated with 40 mg eow dosing, did not show evidence of cumulative toxicity, and showed adverse event rates that were generally stable or decreased with increased mean per-patient exposure.

Increased sensitivity to apoptosis induced by methotrexate is mediated by JNK

OBJECTIVE

Low-dose methotrexate (MTX) is an effective therapy for rheumatoid arthritis (RA), yet its mechanism of action is incompletely understood. The aim of this study was to explore the induction of apoptosis by MTX.

METHODS

Flow cytometry was performed to assess changes in the levels of intracellular proteins, reactive oxygen species (ROS), and apoptosis. Quantitative polymerase chain reaction was performed to assess changes in the transcript levels of select target genes in response to MTX.

RESULTS

MTX did not directly induce apoptosis but rather "primed" cells for markedly increased sensitivity to apoptosis via either mitochondrial or death receptor pathways, by a JNK-dependent mechanism. Increased sensitivity to apoptosis was mediated, at least in part, by MTX-dependent production of ROS, JNK activation, and JNK-dependent induction of genes whose protein products promote apoptosis. Supplementation with tetrahydrobiopterin blocked these MTX-induced effects. Patients with RA who were receiving low-dose MTX therapy expressed elevated levels of the JNK target gene, jun.

CONCLUSION

Our results support a model whereby MTX inhibits reduction of dihydrobiopterin to tetrahydrobiopterin, resulting in increased production of ROS, increased JNK activity, and increased sensitivity to apoptosis. The finding of increased jun levels in patients with RA receiving low-dose MTX supports the notion that this pathway is activated by MTX in vivo and may contribute to the efficacy of MTX in inflammatory disease.

Dermatologist preferences for first-line therapy of moderate to severe psoriasis in healthy adult patients

BACKGROUND

Despite increasing therapies for moderate to severe psoriasis, dermatologists' treatment preferences are unknown.

OBJECTIVE

We sought to assess dermatologists' preferences for first-line treatments and their selection determinants.

METHODS

We surveyed 1000 US dermatologists (500 National Psoriasis Foundation and 500 American Academy of Dermatology members who treat psoriasis) about their preferences for first-line treatment of moderate to severe psoriasis in healthy adults of childbearing age using standardized patient vignettes.

RESULTS

The response rate was 39% (N = 387). Preferred therapies for male and female patients were: ultraviolet (UV) B (40% and 56%, respectively), etanercept (15% and 19%), methotrexate (16% and 4%), and adalimumab (12% and 10%). Of respondents, 66% administered phototherapy in their practice. After adjusting for all physician characteristics, those preferring first-line UVB for male or female patients were significantly more likely to have phototherapy in their practice (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.8-6.6 and OR 2.8, 95% CI 1.5-5.3, respectively) and to have used UVB in more than 10 patients in the last 3 months (OR 8.0, 95% CI 3.9-16.4; OR 9.6, 95% CI 4.3-21.6). Dermatologists in the Midwest were more likely than those in the Northeast to prefer adalimumab first line for male and female patients.

LIMITATIONS

We surveyed only dermatologists with interest in treating psoriasis and elicited their treatment preferences for a single base case scenario. Treatment preferences may differ between survey respondents and nonrespondents.

CONCLUSION

UVB is most commonly preferred as a first-line treatment for moderate to severe psoriasis in healthy adults, and preferences vary based on region, phototherapy availability, and prior treatment use.

Advances in the treatment of moderate-to-severe plaque psoriasis

PURPOSE

Advances in the treatment of moderate-to-severe plaque psoriasis, including new biological agents and related drugs, are reviewed.

SUMMARY

Most patients with psoriasis have mild disease that can be treated with topical agents alone; however, over one third of patients have more-extensive disease, called moderate-to-severe plaque psoriasis. Although effective, traditional therapies, including methotrexate, cyclosporine, acitretin, and phototherapy, have serious adverse effects that limit both the initiation and duration of treatment, necessitating sequential treatment regimens. With the increasing knowledge of the immune nature of the disease, biological agents that target T lymphocytes, tumor necrosis factor (TNF)-α, interleukin (IL)-12, and IL-23 have been used successfully in moderate-to-severe psoriasis. Etanercept, adalimumab, and infliximab are also highly effective in the treatment of moderate-to-severe plaque psoriasis. Ustekinumab, a new agent that targets IL-12 and IL-23, was approved for marketing in 2009 and offers similar efficacy and safety profiles to the anti-TNF agents. While the rapid onset and apparent lack of long-term toxicity of biological agents make them major advances in the treatment of more severe forms of psoriasis, the lack of extensive experience with these agents in patients with psoriasis leaves several unresolved issues that must be addressed before their exact place in therapy can be determined.

CONCLUSION

With the development of biological therapies over the past 10 years, health care providers have a much broader choice of highly effective agents with which to treat patients suffering from moderate-to-severe plaque psoriasis. Though costly to use, biological agents offer considerable advantages over previously available systemic therapies.

Ustekinumab: differential use in psoriasis

Chronic plaque psoriasis is a systemic disease affecting over 3% of the population, and many patients are unsatisfied with their current treatment regimen. With advances in understanding of the pathophysiology of psoriasis, new therapeutic options are being developed. The newest of these agents, ustekinumab, offers patients rapid results and the convenience of four annual subcutaneous doses, with efficacy and safety profiles comparable with those of other biologics. However, ustekinumab has been on the market in the US for less than 2 years and will require years of extensive use before the full adverse event profile is fully understood. The purpose of this paper is to summarize the treatment options currently available for psoriasis, with an emphasis on ustekinumab in order to give prescribers an overview of the available data and allow them to make educated and informed prescribing decisions.

How genetic variation affects patient response and outcome to therapy for psoriasis

Psoriasis is a prevalent chronic inflammatory condition that affects the skin. There are many treatments available for psoriasis but they are not universally effective and some have associated toxicities. Pharmacogenetics and pharmacogenomics explore the relationship between individual genetic variation and drug effect to allow targeted 'personalized' therapy for patients. There has been very limited pharmacogenetic research regarding psoriasis, with most limited to small retrospective case-control studies looking at single-nucleotide polymorphisms in candidate genes involved in drug pharmacokinetics. We review the pharmacogenetic investigation of treatments for psoriasis to date, including emerging pharmacogenomic studies. In addition, we discuss how such genetic data could be incorporated into routine clinical practice and future areas for development in this field.

IL-23-mediated epidermal hyperplasia is dependent on IL-6

Psoriasis is a chronic inflammatory skin disease primarily driven by Th17 cells. IL-23 facilitates the differentiation and induces complete maturation of Th17 cells. Lesional psoriatic skin has increased levels of IL-23 and recent studies show that intradermal injections of IL-23 induce a psoriasis-like skin phenotype in mice. We have now characterized the IL-23-induced skin inflammation in mice at the molecular level and found a significant correlation with the gene expression profile from lesional psoriatic skin. As observed in psoriasis, the pathogenesis of the IL-23-induced skin inflammation in mice is driven by Th17 cells. We demonstrate a dramatic upregulation of IL-6 mRNA and protein after intradermal injections of IL-23 in mice. Using IL-6(-/-) mice we show that IL-6 is essential for development of the IL-23-elicited responses. Despite producing high levels of IL-22, IL-6(-/-) mice were unable to express the high-affinity IL-22 receptor chain and produced minimal IL-17A in response to intradermal injections of IL-23. In conclusion, we provide evidence for the critical role played by IL-6 in IL-23-induced skin inflammation and show that IL-6 is required for expression of IL-22R1A.

Managing inflammatory arthritides: Role of the nurse practitioner and physician assistant

PURPOSE

To review the current management of the inflammatory arthritides, including rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. This review examines the role of the nurse practitioner (NP) and physician assistant (PA) in the management of these chronic diseases.

DATA SOURCES

A review of the scientific literature and current guidelines regarding the management of inflammatory arthritides.

CONCLUSIONS

NPs and PAs play important roles in the interdisciplinary team involved in the treatment of patients with chronic inflammatory arthritic conditions. The management of inflammatory arthritides has evolved with the development of new treatment strategies and is focused on early intervention and minimizing progressive joint damage. NPs and PAs are ideally positioned to educate patients regarding treatment options and other important aspects of the disease process and to monitor disease activity using a number of validated instruments.

IMPLICATIONS FOR PRACTICE

Through active disease management, NPs and PAs can influence their patients to make better, more informed choices regarding treatment, which may optimize patient outcomes.

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the American Academy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients' needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

Rheumatologic disease and the liver

Rheumatologic diseases such as rheumatoid arthritis, systemic lupus erythematosus, Sjögren syndrome, and scleroderma are immunologically mediated disorders that typically have multisystem involvement. Although clinically significant liver involvement is rare, liver enzyme abnormalities may be observed in up to 43% of patients. The biochemical abnormalities are typically mild and transient and the histologic abnormalities are usually nonprogressive. Such biochemical and histologic findings are typically ascribed to the primary rheumatologic condition and require no specific management. In a subset of patients with rheumatologic conditions and liver test abnormalities, further evaluation identifies a coexisting, primary liver disease or medication-related liver toxicity as the cause of the biochemical abnormality. Liver test abnormalities in patients with a coexisting primary liver disease are more likely to be persistent. In such cases, further workup using serologic tests, appropriate imaging studies and liver biopsy may be needed to accurately identify the cause of liver test abnormalities. This article reviews the spectrum of liver-related abnormalities associated with several rheumatologic diseases. Hepatotoxicity related to medications commonly prescribed in such conditions is also discussed.

Assessment and management of methotrexate hepatotoxicity in psoriasis patients: report from a consensus conference to evaluate current practice and identify key questions toward optimizing methotrexate use in the clinic

Experts in psoriasis, hepatology, pharmacokinetics and pharmacogenetics convened to discuss the safety and monitoring of methotrexate with respect to hepatotoxicity when used in the treatment of psoriasis. Methotrexate is an efficacious and cost-effective treatment for psoriasis, but is associated with significant safety issues, particularly relating to hepatotoxicity. Current British, Dutch, German, EU and US guidelines for baseline evaluations, monitoring and prevention of hepatotoxicity in patients with psoriasis receiving methotrexate were evaluated. Liver safety monitoring is currently reliant upon multiple methods, including biopsy, serological tests for biomarkers such as type III procollagen amino terminal propeptide (PIIINP), and liver function tests based on liver enzymes. Monitoring of patients receiving long-term therapy is expected to be improved by the utilization of serum biomarkers currently in development such as the Enhanced Liver Fibrosis (ELF) panel and other non-invasive tests of hepatic architecture, such as fibroelastography, microbubbles and magnetic resonance imaging. Appropriate studies to determine optimal dosing to maximize efficacy and minimize toxicity, potentially utilizing pharmacogenetic principles, are clearly needed. Key questions for future research are identified including needs for optimal screening and monitoring, identification of appropriate biomarkers, assessment of relationships between dosing and safety, utility of liver biopsy, optimal dosing regimens (including route of administration), methods to measure methotrexate levels in blood, and use of methotrexate as a standardized active comparator in trials of experimental drugs used to treat psoriasis.

The use of cyclosporine in dermatology: part I

Cyclosporine is a calcineurin inhibitor that acts selectively on T cells. It has been used in dermatology since 1997 for its US Food and Drug Administration indication of psoriasis and off-label for various other inflammatory skin conditions, including atopic dermatitis, blistering disorders, and connective tissue diseases. In the last decade, many dermatologists have hesitated to use this important drug in their clinical practices because of its toxicity profile. The purpose of this article is to review the mechanism of action of cyclosporine and its current uses and dosing schedules. It is our goal to create a framework in which dermatologists feel comfortable and safe incorporating cyclosporine into their prescribing regimens.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to describe the mechanism of action of cyclosporine, recognize the potential role of cyclosporine in dermatology and the evidence to support this role, and incorporate cyclosporine into his or her prescribing regimens.

The use of cyclosporine in dermatology: part II

Cyclosporine is highly effective in the treatment of a multitude of dermatoses. Concern over its side effect profile has limited its use in dermatology. Adverse effects are, for the most part, dose dependent and related to duration of therapy. Using the recommended monitoring protocols results in a significant decrease in the incidence of cyclosporine-related toxicities. This article provides a comprehensive review of the pharmacokinetics of cyclosporine, potential drug interactions, adverse effects, and recommendations for monitoring in patients treated with cyclosporine. The use of cyclosporine in pregnancy and in the pediatric population is also addressed.

LEARNING OBJECTIVES

After completing this learning activity, participants should be familiar with the monitoring guidelines of cyclosporine, its contraindications, its possible drug interactions, its adverse effect profile, and its use in pregnancy and the childhood and adolescent populations.

Methotrexate in patients with primary biliary cirrhosis who respond incompletely to treatment with ursodeoxycholic acid

BACKGROUND

Approximately 35% of PBC patients have progressive disease despite treatment with UDCA.

AIMS

We offered treatment with methotrexate and colchicine to PBC patients who had not responded fully to UDCA, after at least 1 year of treatment.

METHODS

A total of 91 PBC patients failed to respond adequately to UDCA, defined as patients whose liver biopsies showed persistent interface hepatitis and whose serum alkaline phosphatase levels remained more than 50% above normal after at least 12 months on UDCA. We added colchicine (0.6 mg orally twice daily) for 6 months. If there was no decrease in alkaline phosphatase, methotrexate (0.25 mg/kg lean body weight orally per week) was added. Liver biopsies were performed at least three times: at diagnosis, after a patient had been on UDCA for at least 1 year (mean 3.4 years), and after a patient had been on methotrexate for at least 6 months (mean 2.2 years). A fourth liver biopsy was performed in 51 patients after they had been on methotrexate for at least another year (mean 3.5 years).

RESULTS

From the time that methotrexate was begun until the final visit, there were significant decreases in the mean levels of alkaline phosphatase, 323 to 151, ALT, 73 to 39, fibrosis, 2.5 to 2.0, and inflammation scores, 2.0 to 1.0, (p < 0.0001 for all). Based on pre-specified definitions, 73 patients (80%) responded to methotrexate while 18 (20%) did not.

CONCLUSIONS

In 91 PBC patients who responded incompletely to UDCA, colchicine and methotrexate significantly improved liver enzyme tests and liver histology.

What's new in psoriasis? Analysis of the clinical significance of new guidelines and systematic reviews on psoriasis published in 2008 and 2009

This review summarizes the clinical importance of 18 systematic reviews and guidelines on psoriasis published or indexed between November 2008 and October 2009. The topics covered include guidance on the use of topical, systemic and biological therapies for the treatment of psoriasis; comorbidities associated with psoriasis; and complementary therapies for psoriasis. A similar and more detailed review to this appeared in the 2009 Annual Evidence Update on Psoriasis from NHS Evidence - Skin Disorders in November 2009.

Psoriasis and non-alcoholic fatty liver disease

Several recent studies have found an increased prevalence of non-alcoholic fatty liver disease within psoriasis patients. The exact pathophysiological mechanisms behind these observations are unclear, but are likely related to the high prevalence of obesity and metabolic syndrome within this patient population. Chronic inflammation, mediated by either proinflammatory adipokines or skin-derived cytokines, may contribute to fatty liver disease development by increasing insulin resistance which in turn promotes hepatic lipid accumulation. These same adipokines in addition to hepatic cytokines may act on the skin to influence psoriasis disease severity.

Critical appraisal of quality of clinical practice guidelines for treatment of psoriasis vulgaris, 2006-2009

Numerous international clinical guidelines for management of psoriasis have recently been published. We evaluated the quality of guidelines published between 2006 and December 2009 using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Eight guidelines from five separate working groups fulfilled inclusion criteria and were evaluated. Four used the standards established by the AGREE instrument in the process of development of their guidelines. Each of the guidelines uniformly received high domain scores (i.e., > 90%) for scope and purpose (range of 94-100%), and clarity and presentation (range of 92-100%). Nevertheless, each of the eight guidelines had important shortcomings (item scores < or = 2/4, in which 4 indicates strongly agree and 1 indicates strongly disagree that specific items have been adequately addressed) in at least one item including: stakeholder involvement (by lack of piloting and inadequate determination of patient views), development rigor (inadequate procedure for updating), applicability (by lack of discussion on organizational barriers), and editorial independence (from funding body). Despite the use of predefined standards in their development, important deficiencies exist in the most recent clinical treatment guidelines for psoriasis.

Update of the management of chronic psoriasis: new approaches and emerging treatment options

Psoriasis is a common, chronic inflammatory skin disease which is associated with a number of significant co-morbidities including: impairment of quality of life; cardiovascular disease; and a seronegative arthritis known as psoriatic arthritis. Our understanding of the pathogenesis of psoriasis has developed at a remarkable rate in recent years. These new insights have significantly changed our perception of the condition and have led to the development of several new treatment strategies. Biological agents have proved a major step forward in therapeutic options for psoriasis. The ability to clear, or almost clear, cutaneous disease has changed the outcomes and expectations of many patients with this disease. The impact on both physical and psychological health may be great. This review covers the clinical features and management of psoriasis with specific reference to new therapeutic options.