Therapy with cyclosporine in psoriatic arthritis

Practical recommendations for systemic treatment in psoriasis in case of coexisting inflammatory, neurologic, infectious or malignant disorders (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis; part 2)

Background

Psoriasis patients carry an increased risk for associated comorbidities. Dermatologists have to be aware of the effects of systemic treatments not only on psoriasis but also on co‐occurring diseases. In case of other coexisting inflammatory diseases, the right psoriasis treatment may improve both disorders. For infectious and malignant disorders, some treatments have to be avoided as they may be harmful.

Objective

The primary objective of this project was to collect evidence for the creation of practice guidelines for systemic treatment of psoriasis (BETA‐PSO: Belgian Evidence‐based Treatment Advice in Psoriasis).

Methods

Evidence‐based recommendations were formulated using a quasi‐Delphi methodology after a systematic search of the literature and a consensus procedure involving eight psoriasis experts.

Results

Recommendations are given on the use of systemic treatment in psoriatic arthritis, inflammatory bowel disease, demyelinating disorders, hepatitis B and C, HIV and cancer.

Conclusion

This expert opinion is a practical guide for dermatologists when handling psoriasis patients with these specific conditions.

Clinical potential of apremilast in the treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is a frequent chronic inflammatory disease characterized by joint and skin involvement, and by typical extra-articular manifestations. Although the pathogenesis of PsA is still under investigation, the available evidence suggests the importance of the patient’s genetic background, microbial or environmental triggers, and an imbalance in the adaptive and acquired immune system, resulting in the production of inflammatory mediators. New therapeutic approaches have been proposed, among them the use of modulators of intracellular signals and gene transcription such as PDE4-inhibiting compounds, which are able to modulate the activity of transcription factors such as CREB and NF-κB and therefore the synthesis of inflammatory mediators, resulting in immunoregulation. This paper summarizes the mechanism of action of apremilast, a PDE4 inhibitor, and the clinical data available on its clinical efficacy and safety profile in the treatment of PsA patients.

Psoriasis and psoriatic arthritis: separate or one and the same?

The presence and severity of skin and joint symptoms in patients with psoriasis and psoriatic arthritis frequently do not correspond, a discrepancy that has raised the question of whether they represent two related but different disease processes. The fact that some agents seem to work preferentially in one state over the other reinforces this idea. However, there are also several agents with combined efficacy against cutaneous and articular inflammation that appear to support the existence of a common aetiology. Here we review the clinical, epidemiological and genetic evidence for and against a common pathogenesis for the two diseases. We then discuss the cellular and molecular targets of their selected therapies and how they potentially implicate effector pathways as a common immunopathogenic mechanism. Finally, we examine a recently proposed model of psoriasis pathogenesis involving type 1 interferon-producing plasmacytoid dendritic cells and how it may provide further clues to the aetiological links between psoriasis and psoriatic arthritis.

The treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic, autoimmune, seronegative inflammatory arthritis characterized by varying degrees of axial and peripheral arthritis. Here, we review the literature on the pharmacological management of PsA and present a simple treatment algorithm based on the available information. Although PsA management must be individualized to the degree and type of joint pain and inflammation, in general, nonsteroidal antiinflammatory drugs (NSAIDs) still represent first-line treatment of mild PsA. Second-line therapy includes older agents such as gold salts, methotrexate, sulfasalazine, and cyclosporine. The tumor necrosis factor alpha (TNF-alpha) antagonists represent the most recent major advance in the clinical management of PsA.

Diagnosis and treatment of psoriatic arthritis

Psoriatic arthritis is a chronic, heterogeneous disease whose pathogenesis is unknown, although genetic, environmental, and immunologic factors play major roles. Psoriatic arthritis can follow an aggressive clinical course, and differentiating it from other arthropathies is sometimes difficult. Diagnosis of psoriatic arthritis is based on history, physical examination, the usual absence of rheumatoid factor, and characteristic radiographic features. At least 40% of patients with psoriatic arthritis develop radiographically detectable joint destruction; therefore, proper diagnosis and early treatment can have a significant impact on disease course and outcome. Understanding the pathogenesis of psoriatic disease has led to the use of several biologic agents that work by modulating T-cell signaling or by inhibiting key cytokines involved in inflammation, such as tumor necrosis factor (TNF). TNF inhibitors have demonstrated excellent efficacy in resolving skin and joint disease in patients with psoriatic arthritis and have been shown to be safe agents in various inflammatory disorders. This article reviews the diagnostic and treatment challenges of psoriatic arthritis as they relate to pathogenesis and burden of disease.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, differential diagnosis, and treatment of psoriatic arthritis.

Understanding psoriatic arthritis

Previously, psoriatic arthritis was considered an uncommon, generally benign variant of ankylosing spondylitis or rheumatoid arthritis, with few therapeutic options. It is now recognized as a distinct, potentially serious disorder that can be effectively managed with a number of new agents.

Evaluation and management of psoriatic arthritis: the role of biologic therapy

Clinicians often view psoriatic arthritis (PsA) as a rather minor arthritic disorder because many are unaware of the substantial damage, disability, and reduced quality of life that patients with this disease can suffer. Compared with better-studied arthritic conditions, such as rheumatoid arthritis (RA) with well-known consequences of disease progression, PsA does not elicit the same urgency to treat early and aggressively. This is largely owing to the lack of predictive epidemiologic data regarding disease progression in PsA. However, numerous studies indicate that PsA and RA are comparable in terms of overall severity of joint involvement and disability over equivalent disease duration. Many of the drugs traditionally used for PsA therapy are also used to treat RA, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, methotrexate (MTX), sulfasalazine, cyclosporine, etretinate, auranofin, intramuscular gold, and azathioprine. All of these drugs have significant risk of toxicity over long-term use, and all provide variable efficacy. This makes it difficult for clinicians to make sound risk-benefit assessments regarding treatment or nontreatment of PsA, because the risks of disease progression cannot be weighed against the risks of therapy. The newer biologic antirheumatic drugs appear to combine greater efficacy of treatment with significantly less toxicity by targeting specific mediators involved in the pathogenesis of PsA.

Open-label study of infliximab treatment for psoriatic arthritis: clinical and magnetic resonance imaging measurements of reduction of inflammation

OBJECTIVE

To evaluate infliximab efficacy and safety in disease-modifying antirheumatic drug-unresponsive psoriatic arthritis (PsA).

METHODS

In a 54-week, open-label, compassionate-use study, 10 patients received intravenous infliximab (5 mg/kg; weeks 0, 2, 6; individualized dosing after week 10). Patients continued their current therapy (stable dose) until week 10. Assessments were performed at weeks 2, 6, 10, and 54. Magnetic resonance imaging (MRI) objectively measured joint inflammation at weeks 0 and 10.

RESULTS

Patients achieved a 20% improvement according to the American College of Rheumatology (ACR) criteria (ACR20) in all patients by week 2; 8 patients improved 70% (ACR70) at week 10; 6 patients maintained ACR70 after week 54. Week 10 MRI revealed an 82.5% mean reduction in inflammation from baseline, and psoriasis area and severity index scores were reduced by 71.3% +/- 16.7%. There were no significant adverse events, severe infections, or infusion reactions.

CONCLUSION

Infliximab was effective, safe, and well tolerated in PsA. Arthritis and psoriasis improved in all patients during the 54-week evaluation. Further investigation of the use of infliximab for PsA and psoriasis is warranted.

Open Trial of Leflunomide for Refractory Psoriasis and Psoriatic Arthritis

Leflunomide was recently approved for the treatment of rheumatoid arthritis. Its role in the treatment of psoriasis and psoriatic arthritis is unclear. Twelve consecutive psoriatic arthritis patients who had not responded to at least one disease modifying anti-rheumatic drug (DMARD) were started on leflunomide alone or in addition to another DMARD. Global assessment of improvement in psoriasis and psoriatic arthritis by the treating rheumatologist was scored on a 0-3 scale. After 2-3 months of treatment, 8 patients had moderate to marked improvement in both psoriasis and psoriatic arthritis. The improvement in modified tender joint counts, patient's global assessments, and grip strengths was statistically significant. However, physicians' global assessments and the modified swollen joint counts did not reach a significant difference. Three patients whose toxicity necessitated the temporary discontinuation of the drug were able to resume the drug at lower dosage with clinical benefit. Leflunomide may prove to be a useful agent for the treatment of recalcitrant cases of psoriasis and psoriatic arthritis.

Safety profile and causes of withdrawal due to adverse events in systemic lupus erythematosus patients treated long-term with cyclosporine A

Several case reports and uncontrolled trials have established the use of cyclosporine A (CsA) in systemic lupus erythematosus (SLE) but some concerns have been raised because of its kidney damaging effects. We here report the results of a retrospective follow-up study designed to assess the safety profile and causes of discontinuation due to adverse events in SLE patients treated with CsA. We treated 56 SLE patients with oral CsA at doses of 3-5 mg/kg for an average of 26 months. Adverse events not leading to the discontinuation of therapy were observed in 62.5% of the patients, the most frequent being hypertrichosis. CsA was stopped because of the occurrence of side effects in 9/56 (16%) of the patients. The most common were nephrotoxicity (3/9) and the occurrence of tremors (3/9). These effects were always reversible within three months of CsA withdrawal. The patients who were older than 40 y had a significant slightly increased risk of stopping CsA therapy for any adverse events (RR 1.08; CI 95% 1.03-1.14). In comparison with previous studies, this study involved a larger cohort of SLE patients who were evaluated for a longer period of follow-up, and confirmed the good tolerability of CsA in these subjects.

Effect of lithium on cyclosporin induced nephrotoxicity in rats

Psychoactive drugs provide essential intervention in the care of transplant recipients, yet little is known of their interaction with immunosuppressants such as cyclosporin (CSA). Lithium (Li) is an invaluable drug for the treatment of manic disorders in organ transplant patients. As both these drugs are known to produce renal toxicity, the concomitant use of CSA and Li may be potentially harmful. The present study was undertaken to investigate the effect of CSA and Li chloride individually and in combination on renal structure and function of rats. Male Sprague-Dawley rats were divided into the following eight groups of seven animals each: group I, control (vehicle only); group 2, Li (2 mEq/ kg i.p.) alone; group 3, CSA 12.5 mg/kg (subcutaneous); group 4, CSA 25 mg/kg; group 5, CSA 50 mg/kg; group 6, CSA 12.5 mg/kg + Li; group 7, CSA 25 mg/kg + Li; and group 8, CSA 50 mg/kg + Li. The drugs were given once a day for seven days; Li being administered 30 min before CSA. Twenty four hours after the last dose of drugs the animals were sacrificed and blood samples were analyzed for blood urea nitrogen (BUN), serum creatinine (SCr), CSA and Li levels. The left kidney was analyzed for malondialdehyde (MDA) and conjugated dienes (CD) levels and right kidney was used for histopathological studies. Our results showed that Li alone did not produce any significant renal toxicity, whereas CSA dose dependently caused structural and functional changes in kidneys. However, significantly higher structural and functional impairment was observed in the animals treated with Li plus CSA as compared to CSA alone treated animals. Several fold increase in blood Li level was also noticed in the rats concomitantly treated with CSA and Li. A significant increase in MDA and CD in the rats treated with CSA plus Li suggests the role of oxidative stress in drug induced nephrotoxicity. These findings clearly demonstrate that even non toxic doses of Li may significantly exacerbate CSA induced nephrotoxicity in rats. The enhanced nephrotoxicity following concomitant use of these drugs may be attributed to significant increase in the bioavailability of Li and enhanced oxidative stress. Further clinical studies are warranted to investigate the interaction of these nephrotoxic drugs in human subjects.

Immunosuppressant-induced nephropathy: pathophysiology, incidence and management

Immunosuppressant-induced nephrotoxicity, in particular chronic progressive tubulointerstitial fibrosis/arteriopathy induced by the calcineurin inhibitors cyclosporin and tacrolimus, has become the 'Achilles heel' of immunosuppressive agents. The use of calcineurin inhibitors as primary immunosuppressants in hepatic and cardiac transplantation has led to end-stage renal disease and dialysis. Calcineurin inhibitor-induced acute renal failure may occur as early as a few weeks or months after initiation of cyclosporin therapy. The clinical manifestations of acute renal dysfunction are caused by vasoconstriction of renal arterioles, and include reduction in glomerular filtration rate, hypertension, hyperkalaemia, tubular acidosis, increased reabsorption of sodium and oliguria. The acute adverse effects of calcineurin inhibitors on renal haemodynamics are thought to be directly related to the cyclosporin or tacrolimus dosage and blood concentration. However, new clinical data indicate that calcineurin inhibitor-induced chronic nephropathy can occur independently of acute renal dysfunction, cyclosporin dosage or blood concentration. Several strategies have been evaluated to attenuate cyclosporin-induced nephropathy, but their efficacy remains unknown. Cytokine release syndrome associated with the use of muronomab-CD3 (OKT-3) can also contribute to the pathogenesis of transient acute tubular necrosis and renal dysfunction following renal transplantation. Continued research and clinical experience should provide information regarding the aetiology of cyclosporin-induced chronic progressive tubulointerstitial fibrosis/arteriopathy and its potential treatment.