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PDAT4 > 27 - Psoriasis > Flashcards

27 - Psoriasis Flashcards

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1
Q

Which PSORIASIS DRUG is
PREGNANCY CATEGORY X?

A

TOPICAL RETINOIDS

Tazarotene 0.1% & 0.05% cream/gel

Also:
Methotrexate** + **Acretin

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2
Q

Which SYSTEMIC PSORIASIS Drug?

Calcineurin Inhibitor + Blocks Lymphocytes
T-cells & IL-2 containing lymphokines

Short Term Therapy < 12 weeks
to reduce risk of nephrotoxicity
also need to TAPER off dose for D/C
1mg/kg/day each week to prolong relapse
Rebound Psoriasis very likely

A

CYCLOSPORINE

Moderate - Severe Plaque Psoriasis
for inducing remission & maintanence

CYP34A SUBSTRATE

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3
Q

AMJEVITA
is a Biosimilar to BRM?

A

ADALIMUMAB = Humira
starts with A

TNF-a inhibitor

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4
Q

ACRETIN - ADRs / Monitoring
oral Retinoid

A
  • *PREGNANCY CATEGORY X**
  • unless using BC & willing to continue 3 years after treatment*
  • *Avoid ALCOHOL**
  • *during** & for 2 months after DC

Monitor:
TG’s & Liver Chemistry

ADR:

  • *Opthalmic** - photosensitivity / color vision / night vision
  • *GI** - hepatitis / jaundice / liver enzyme elevation
  • *Common**: HIGH TG’s / dry mouth/eyes/lips / brittle nails / alopecia
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5
Q

TOPICAL RETINOIDS
Tazarotine 0.1% & 0.05% cream/gel

ADR’s

A

HIGH incidence of irritation @ Application Site
DOSE DEPENDENT
causes : burning / stinging / itching / erythema

  • can be MINIMIZED by using:*
  • *creme formulation / alternate day app**
  • LIMIT treatment to 30-60 min*
  • *use moisturizers**

can be used in combo with topical corticosteroids

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6
Q

Biologic Response Modifiers = BRMs

Psoriasis Indications

Contraindications / Risks

A

Considered for patients with:
Moderate - Severe Psoriasis
when Other systemic agents are
INADEQUATE or CONTRAINDICATED

Immunomodulatory effects cause an:

  • *Increased Risk of INFECTION**
  • *Sepsis / TB reactivation / Opportunistic Infections**

NO LIVE VACCINES

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7
Q

Cyclosporine
ADR / Monitoring

A

Short Term Therapy <12weeks
Due to NEPHROtoxicity
Monitor
baseline BP, Scr, serum urea nitrogen, TG, CBC, uric acid, K, Mg should be taken, and rechecked every 2 weeks for first 12 weeks and monitored monthly after

AE:
renal toxicity, hypertension, hypertriglyceridemia (reversible upon discontinuation), hirsutism, risk of non- melanoma skin cancers increases with duration of treatment

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8
Q

Which PSORIASIS Drug?

Useful for patients with:
Moderate-Severe inverse psoriasis
VVV
affects INTERTRIGINOUS AREAS or FACE

A
  • *TOPICAL CALCINEURIN INHIBITORS = CNI**
  • *Pimecrolimus 1% cream (elidel) // Tacrolimus 0.1%**

LESS irritating vs Calcipotriol

  • *&**
  • AVOIDS* steroid ADR’s like skin atrophy
  • but steroids still may be more effective*

BBW = link between lymphoma & skin cancer

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9
Q

HIGHEST Potency Topical Steroid
for Psoriasis

Indications / Drug

A

indicated for:
VERY THICK PLAQUES
Plaques on:
PALMS or SOLES

BETAMETHASONE 0.5%

CLOBETASOL 0.05%

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10
Q

Topical CorticoSteroid ADRs

Psoriasis

A

Cutaneous ADRs
skin atrophy / acne / dermatitis / folliculitus
hypopigmentation / striai

Systemic ADRs
super potent // WIDE-SPREAD use of mid-potency agents
HPA axis suppression / cushings syndrome
Osteonecrosis / cataracts / glaucoma

TachyPhylaxis with prolonged use

Pregnancy CAT C

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11
Q

Which PSORIASIS DRUG is a:
CYP3A4 SUBSTRATE?

A

CYCLOSPORINE

Inhibitors –> INCREASE CSA concentration
veramapil / diltiazem / amiodarone / macrobide abx
allopurinol / SSRI / antifungals / CIPRO / grapefruit

Inducers –> decrease CSA conc.
anticonvulsnats / phenytoin / phenobarbital
rifAMPin / st johns / efavirenz

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12
Q

NON-Pharmacological Therapy

Psoriasis

A

Recommended THROUGHOUT ALL TREATMENT
along with anything else

STRESS reduction strategies

Moisturizers // Oatmeal Baths

  • *SPF 30**
  • *Skin Protection**

AVOID HARSH SOAPS // Detergents

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13
Q

Cyclosporine

Dosing Considerations

A
  • *Calcineurin Inhibitor**
  • blocks lymphocytes*

Dose should be:
Titrated to LOWEST effective dose for maintanence
to PREVENT RELAPSE

For DISCONTINUATION:
decrease dose 1mg/kg/day each week to prolong relapse
to avoid REBOUND PSORIASIS

  • *Short Term Therapy <12weeks**
  • reduce risk for nephrotoxcity*
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14
Q

MTX
Risk Factors for Hepatotoxcity

A

If they have these RISK FACTORS:
Consider LIVER BIOPSY
or if they have
MTX cumulative dose of 3.5-4g,

Hepatotoxicity Risk Factors:
H/O of moderate alcohol consumption
persistantly abnormal liver chem
history of liver disease = Hep B/C
FamHistory of liver disease
diabetes / Obesity / no FOLATE while on MTX

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15
Q

What is the MoA of these BRMs for Psoriasis?

Ustekinumab = Stelara

A

IL-12 / IL-23
inhibitor

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16
Q

Other Types of Psoriasis

except of PLAQUE psoriasis

A

Gluttate
small DOT like lesions = 2nd most common

  • *Pustular**
  • NOT infectious, pus has WBC*

Inverse
in SKIN FOLDS –> obese people

Erythrodermic
VERY SEVERE –> entire body / painful / temperature

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17
Q

Topical Vitamin D Analogs

ADRs

A

Cutaneous
Mild Irritant Contact dermatitis
others:
burning / pruritis / edema / itching / peeling /dryness

SYSTEMIC:
HYPERcalcemia // PTH SUPRESSION
rare unless using >5mg calcipotriol

Pregnancy Category C

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18
Q

Lower Potency Topical Steroid
for Psoriasis

Indications / Drug

A

indicated for:
INFANTS
face / interriginous / thin skin

HYDROCORTISONE 1%

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19
Q

Anthralin

Indication / ADR

A

Psoriasis Treatment
typically with UVB Phototherapy

Short Contact Athralin Therapy = SCAT
is preferred, AAA for 2 hours –> wipe off

  • not commonly used*
  • risk of* severe skin irritation
  • do NOT use on FACE or Intertriginous areas*
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20
Q

Which TOPICAL PSORIASIS DRUG

has a BLACK BOX WARNING?

  • possible link between the drug and:*
  • *lymphoma & skin cancer**
A

CALCINEURIN INHIBITORS

Pimecrolimus 1% (Elidel)

Tacrolimus 0.1%

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21
Q

INFLECTRA
is a Biosimilar to BRM?

A

INFLIXIMAB = Remicade

TNF-a inhibitor

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22
Q

Phototherapy

UVB

Indications / Treatments

Study These Flashcards
A

for Moderate - Severe Psoriasis

Narrowband UVB or Broadband UVB
given with:
Crude Coal Tar or Anthralin
for enhanced efficacy

LASER treatment has HIGHER UVB dose = FASTER results

Contraindicated in patients with
history of melanoma or multiple nonmelanoma skin cancers

23
Q

Which PSORIASIS drug
can NOT be used with
UVB LIGHT PHOTOTHERAPY

Study These Flashcards
A
  • *TOPICAL SALICYLIC ACID**
  • *keratoytic properties –> SCALP PSORIASIS**

may reduce EFFICACY
when used with UVB light phototherapy

24
Q

BRMs

Monitoring / Screening

Study These Flashcards
A

BBW = Fatal Infections / Malignancies

Monitoring:
TB Testing // ANC
Baseline LFT & periodically
H/o or signs of Malignancy
COPD / CHF / GI perforation

25
**Which PSORIASIS drug?** MoA: **Binds to _receptors_**, which results in ***inhibition* of KERATINOCYTE proliferation** & **enhancement of KERATINOCYTE differentiation** ***Inhibits* T-lymphocyte Activity**
**_TOPICAL VITAMIN D ANALOGS_** **Calcipotriol / CalcipoTriene** cream / solution / ointment foam * *Calcitriol Ointment** * for sensistive skin / skin folds*
26
* *Which PSORIASIS drug is * _INACTIVATED by UV-A LIGHT?_***
**_TOPICAL VITAMIN D ANALOGS_** **Calcipotriol / CalcipoTriene / Calcitriol Ointment** **Apply AFTER UVA light exposure**
27
**Which SYSTEMIC THERAPY of PSORIASIS** **is the _GOLD STANDARD_**? and when is there an **EXCEPTION?**
**_METHOTREXATE_** is gold standard SAFER alternative to CSA ***_unless PRE-EXISTING LIVER DISEASE_***
28
**Which Psoriasis Drug?** **_Keratolytic Properties_** Used in various: * *shampoo / bath oil formulations** for patients with: * *_SCALP PSORIASIS_**
**_TOPICAL SALYCYLIC ACID_** Typically used in: **COmbination w/ topical corticosteroids** VVV ENHANCES **steroid penetration --\> increase efficacy** **_CAN BE USED IN PREGNANCY_** *BUT:* ***_AVOID in CHILDREN_*** also **Systemic Absorption with 20% BSA & RENAL IMPAIRMENT**
29
**Which PSORIASIS Drug? Indication?** * *_PHOSPHODIESTERASE-4 INHIBITOR​_ * reduces* production of CYTOKINES**
**_APREMILAST_** = **Otezla** Indicated for treatment of: **Moderate - Severe Plaque Psoriasis** for those who are **candidates for** **phototherapy or systemic therapy**
30
**What is the MoA of these BRMs for Psoriasis?** **Etnercept = Enbril** **Certolizumab Pegol = Cimzia**
**_TNF-a Inhibitor_** Also: **Adalimumab = Humira** **Infliximab = Remicade IV**
31
**What is the MoA of these BRMs for Psoriasis?** **Secukinumab = Cosentyx** **Brodalumab = Siliq** **Ixekizumab = Talz**
**_IL-17_** inhibitor
32
**Which Psoriasis DRUG?** MoA: Normalizes abnormal **keratinocyte differentiation** *diminishes* **keratinocyte HYPERproliferation** CLEARS **inflammatory infiltrate in psoriatic plaque**
**_TOPICAL RETINOIDS_** **Tazarotine 0.1%** & **0.05% cream/gel** ONCE DAILY **CATEGORY X** Effective in: **CLEARING psoriatic plaque Lesions & Achieving REMISSION**
33
* *Genetic Factors:** * *Psoriasis**
**Family History** **_PSORs1_** on chromosome 6p is KEY gene --\> **50% of heritability** _Major Psoriasis Susceptibility genes:_ * *_HLA_** * *_Cw6 TNF-a Interleukin-23_**
34
**Pharmacologic Therapy for Psoriasis** **Mild-Moderate Severity**
**_TOPICAL TREATMENTS_** are std of care ## Footnote **CorticoSteroids** **Vitamin D Analogs** **Retinoids** **Salycylic Acid** **Calcineurin Inhibitors = CNI**
35
**Phototherapy** **UVA** **Indications / Treatments**
**_for Moderate - Severe Psoriasis_** * *_P+UVA_** * ***_P_**soralens** = Photosensitizer to ENHANCE efficacy **MOST EFFICACIOUS PHOTOTHERAPY TREATMENT** **_*topical VITAMIN D analogs are INACTIVATED by UVA light*_** *_Contraindicated in patients with_* history of **melanoma** or multiple **nonmelanoma skin cancers**
36
**MTX Monitoring for those WITHOUT hepatoxicity Risk factors** Hepatotoxicity Risk Factors: H/O of **moderate alcohol consumption** persistantly **abnormal liver chem** history of **liver disease = Hep B/C** **FamHistory of liver disease** **diabetes / Obesity / *no FOLATE* while on MTX**
**_Patients W/O hepatotoxic risk factors_** **Liver Chemistry** check every **1-3 months** Still: **consider LIVER BIOPSY** if **5/9 AST levels** are **ELEVATED over course of 12 months**
37
**Which PSORIASIS drug is considered the _Safest LONG-TERM topical treatment_**?
* *_Topical VITAMIN-D Analogs_** * *Calcipotriol** = **cream / solution / ointment / foam** * *Calcitriol OINTMENT** * less irritation in* **sensitive skin areas = skin folds** **Can be used in COMBINATION w/ topical steroid** more effective with comination more expensive though
38
**Which PSORIASIS drug?** **Direct anti-inflammatory benifits** due to its effects on **T-Cell Gene Expression** & **cytotoxic Effects** *blocks* **_DIHYDROFOLATE REDUCTASE_** ***Inhibits FOLATE Synthesis***
**_METHOTREXATE_** **Gold Standard for Psoriasis** safer alternative vs CSA, *unless pre-existing liver disease* **_Pregnancy Catagory X_**
39
**Which SYSTEMIC THERAPY of PSORIASIS?** Active metabolite of: aetretinate, **Vitamin A acid derivative,** **oral retinoid** As MONOtherapy, initial response **may be MORE rapid than MTX** In patients with **SEVERE inflammatory psoriasis** *low dose (25mg/day) is not recommended as monotherapy* Commonly used in **COMBO w/ PHOTOTHERAPY**
**_ACRETIN_** **Oral Retinoid** **Moderate-Severe Psoriasis** often **WITH PHOTOTHERAPY**
40
**Which DRUG THERAPY for Psoriasis?** **Anti-Inflammatory // Antiproliferative Immunosuppresive / Vasoconstrictive** mech: **binds to intracellular corticoid receptors & regulates gene transcription**
**_TOPICAL CORTICOSTEROIDS_** **Ointmets --\> ENHANCE drug penetration** & have the **most potent formulations** *patients might prefer lotion/cream for daytime use* **3 Levels of Potency**
41
**Epidemiology / Etiology Psoriasis**
Male = Female * *Two Peaks**: * *20-30** & **50-60 y/o** **T-lymphocyte-mediated systemic inflammatory disease** **Epidermal HYPERplasia & Dermal Inflammation** Caused by: **Genetic & Environmental Influences**
42
**Apremilast = Otezla** **Dosing / ADR**
**PHOSPHODIESTERASE-4 INHIBITOR** **Gradually INCREASE dose over 5 days** until **Dose of 30mg BID** _*for SEVERE renal impairment --\>* **30mg QD**_ ADR: **DIARRHEA** - shortterm initial Treatment // **Nausea / headache**
43
**_Mid-High_ _Potency Topical Steroid_** for **Psoriasis** ## Footnote **Indications / Drug**
indicated for: **ADULTS + other areas of the body** *NOT face / interriginous / thin skin* **_CLOBETASOL 0.05%_** for **scalp - foam / shampoo / spray** **Spray / Foams = patient preferred, but higher cost**
44
**Comorbidities with Psoriasis**
Patients with Psoriasis have **significant associated comorbidities: _Psoriatic Arthritis_**=**PsA** * *Metabolic Syndrome:** * *3x** more likely to have **MI** or **STROKE** * *5x** more likely to **develop Diabetes** **Crohn's Disease / MS / T-cell lymphoma** * *_Psychiological Illnesses_** * *ANX / Depression / Alcoholism**
45
**Clinical Presentation of PLAQUE PSORIASIS**
Appear on: **Scalp / Knees / Elbows / Lower Back** **NAIL INVOLVEMENT** 50% have fingernail / 35% have toenail **30% of patients have PsA = Psoriatic Arthritis** 90% of patients with Psa have **Nail involvement**
46
**Systemic Therapies** **Indication**
* *Mainstay of treatment for** * *_Moderate - Severe Psoriasis_** * topical therapies are adjuncts* Traditional Agents: **Acetretin / Cyclosporine / MTX** NEWER AGENTS: * *_Phosphodiesterase-4 Inhibitor_** * *BRM Biologic Response Modifer Agents -Injectables**
47
**Appropriate Use of TOPICAL STEROIDS** **for Psoriasis**
* *_Potency Class 1_** * LIMIT* duration to **2-4 weeks** due to risk of: * *cutaneous / systemic ADRs** **Frequency of use should be *_gradually reduced_*** once clinical response is seen = TAPE **BID application is common** **Pule Dosing also**
48
**Environmental Risk Factors Psoriasis** **Drugs as well**
Drugs that exacerbate **pre-existing psoriasis**: **Lithium / NSAIDs / Chloroquine B-adrenergic blockers / Fluoxetine / CORTICOSTEROID withdrawal** ## Footnote **INFECTION / Injury to Skin** **OBESITY / STRESS**
49
**Methotrexate** **Drug Interactions / ADR**
**_Pregnacy Category X_** _DI due to **ALBUMIN** binding:_ **Salicylates / phenytoin / trimethoprim / ciprofloxacin / thiazides** _DI from **Acidic Drugs:**_ **Salicylates** or **VITAMIN C** --\> INCREASE MTX _ADR:_ **liver toxicity / nausea / pulmonary toxicity / pancytopenia**
50
**_Coal Tar_** **Indication / ADR**
**_Psoriasis Treatment_** typically with **UVB Phototherapy** Can be helpful as a: **Adjunct w/ TOPICAL CORTICOSTEROIDS** * LIMITED EFFICACY* * *WITHOUT PRESCRIPTION** as a: * *shampoo / cream / lotion / oil / oinmetn**
51
**Classification of** **MODERATE - SEVERE** **Plaque Psoriasis**
*NO LAB TEST FOR PSORIASIS* **_\>5 - 10% of BSA_**
52
**What is the MoA of these BRMs for Psoriasis?** **Tildrakizumab = Ilumya** **Guselkumab = Tremfya**
**_IL-23_** inhibitor
53
**ELREZI is a Biosimilar to BRM?**
**_Enbrel_** = **Etanercept** Also starts with E **TNF-a inhibitor**

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