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Understanding Psoriasis Medications (cont.)

Other Systemic Agents for Psoriasis

Antimetabolites, Immunosuppressives, and Biologic Response Modifiers

These agents are potent drugs given by mouth or injection. They block inflammation and have effects on the immune system. The effect on skin is probably secondary to the effect on white blood cells.

Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), ustekinumab (Stelara), methotrexate (Rheumatrex), and cyclosporine (Sandimmune, Neoral) are in this group of biologic response modifier drugs. They may be prescribed for moderate to severe psoriasis and psoriatic arthritis.

How these drugs work: These medications can block inflammation. They are used to treat people with severe disabling psoriasis who have not responded to or tolerated other treatments.

  • Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), ustekinumab (Stelara): These are proteins, also called "biologicals," that are produced by microorganisms and work on the immune system by blocking certain specific proteins of the immune response. For example, tumor necrosis factor (TNF) is involved in inflammation and is blocked by three of these medications. They all are expensive.
    • Who should not use adalimumab, etanercept, ustekinumab, or infliximab: Individuals with an allergy to these medications and those with a serious infection should not use these drugs.
    • Use:
      • Adalimumab is self-administered as an injection every two weeks.
      • Etanercept is given as an injection two times per week. The drug can be injected at home. Rotate the site of injection (thigh, upper arm, abdomen). Do not inject into bruised, hard, or tender skin.
      • Infliximab must be administered in the doctor's office. It is an intravenous (IV, given into the vein) infusion that is administered slowly over two hours. Initially, three doses are administered within a six-week period, and then the drug is administered every eight weeks for maintenance.
      • Ustekinumab is administered by injection every three to four months after a short induction phase.
    • Drug or food interactions: The safety and efficacy of these medications in patients receiving other immunosuppressive drugs have not been evaluated. Patients receiving these medications may receive concurrent vaccinations, except for live vaccines, such as the MMR.
    • Adverse effects: Serious infections may develop and the therapy should be discontinued if they occur. Possible adverse effects include injection-site pain, redness and swelling at injection site, and headaches. Rarely, lupus-like symptoms, lymphoma, reactivation of tuberculosis, and heart failure have been reported (treatment is stopped if symptoms develop).
  • Methotrexate (Rheumatrex): This drug is used to treat plaque psoriasis and psoriatic arthritis. However, it is sometimes not effective.
    • Who should not use methotrexate: Women who are planning to get pregnant or who are pregnant should not take this drug. Men must not take this drug if there is a possibility of getting their partners pregnant because it can go into the sperm. Additionally, people with the following conditions should not use methotrexate:
      • Methotrexate allergy
      • Alcoholism
      • Liver or kidney problems
      • Immune deficiency syndromes
      • Low blood cell levels
    • Use: Methotrexate is taken by mouth (tablet) or as an injection once per week.
    • Drug or food interactions: Tell the doctor if any nonsteroidal anti-inflammatory drugs (Motrin, Advil, Aleve, aspirin) are being taken because these may act with methotrexate and cause adverse symptoms.
    • Adverse effects: The doctor will order blood tests to check blood cell count and liver and kidney function on a regular basis. Methotrexate may cause toxic effects on the blood, kidneys, liver, gastrointestinal tract, lungs, and nervous system. A liver biopsy may be needed to check the health of the liver, especially after prolonged use.
  • Cyclosporine (Sandimmune, Neoral)
    • Who should not use cyclosporine: Individuals with the following conditions or treatments should not take cyclosporine:
      • Cyclosporine allergy
      • Uncontrolled hypertension
      • Kidney problems
      • Cancer
      • PUVA (UV-A light therapy combined with medications that make the skin sensitive to light) or UV-B light therapy (may increase cancer risk)
    • Use: Cyclosporine is taken by mouth once a day.
    • Drug or food interactions: Many drug interactions exist. Carbamazepine (Tegretol), phenytoin (Dilantin), isoniazid, rifampin (Rifadin), and phenobarbital may decrease cyclosporine blood concentrations; azithromycin (Zithromax), itraconazole (Sporanox, Onmel), nicardipine, ketoconazole (Nizoral, Xolegel, Extina), fluconazole (Diflucan), erythromycin (E-Mycin, Eryc, Ery-Tab, Pce, Pediazole, Ilosone), verapamil (Calan, Verelan, Verelan PM, Isoptin, Isoptin SR, Covera-HS), grapefruit juice, diltiazem (Cardizem, Dilacor, Tiazac), aminoglycosides, acyclovir (Zovirax), amphotericin B, and clarithromycin (Biaxin) may increase toxicity; acute kidney failure, muscle breakdown and muscle pain may worsen when cyclosporine is taken concurrently with lovastatin (Mevacor, Altoprev).
    • Adverse effects: The doctor will order tests to check kidney function, may monitor levels of cyclosporine in the blood, or may order other blood tests while an individual is on this medicine. Cyclosporine may increase the risk of infection or lymphoma, and it may cause kidney damage producing high blood pressure.
  • Apremilast (Otezla)
    • Who should not use apremilast: Anyone with a known sensitivity to the drug
    • Use: This is a newly developed oral drug for the treatment of psoriasis and psoriatic arthritis. Its efficacy is touted as being similar to the biologic response modifiers. Major side effects seem to be gastrointestinal so that it is recommended to start with a low dose and gradually increase it to the full therapeutic amount over about a week to avoid intolerable GI symptoms.
    • Adverse events: Major adverse events are gastrointestinal upset and subsequent weight loss.
Medically Reviewed by a Doctor on 6/27/2014

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