PsA - Block 1

Question 1

What are the triggers of psoriasis?

Answer 1

1. Stress
2. Seasonal changes
3. Medications

Question 2

What medications can induce psoriasis?

Answer 2

1. NSAIDs
2. Anti-malarial/ACEI
3. Inderal (B-blockers)
4. Lithium
5. Steroid withdrawal/SSRI

Question 3

Lesion sx of plaque psoriasis?

Answer 3

1. Clearly distinguished from normal skin
2. Covered by silver, flaking scales
   * Auspitz sign: Removal accompanied by fine points of bleeding
3. Koebner phenomenon: May develop at sites of trauma or injury

Question 4

Skin sx of plaque psoriasis?

Answer 4

Mild psoriasis — defined as ≤ 3% BSA involvement

Moderate psoriasis — defined as 3 – 10% BSA or PASI ≥ 8

Severe psoriasis — “Rule of 10”
* BSA ≥ 10%
* PASI ≥10
* DLQI ≥ 10

Question 5

What are the concerns of having untreated psoriasis?

Answer 5

PsA

Question 6

What is psoriatic diagnosis based on? Classifications

Answer 6

Recognition of characterisitc psoriatic lesions

Mild, moderate, severe

Question 7

What is the objective evaluation of the extent of psoriasis?

Answer 7

1. BSA
2. Psoriasis Area & Severity Index (PASI)

Question 8

What is the estimation of BSA psoriatic involvement?

Answer 8

1. Palm size = 1% BSA
2. Head & neck involvement = 10% BSA
3. Both upper limbs = 20% BSA
4. Trunk involvement = 30% BSA
5. Both lower limbs = 40% BSA

Question 9

What are the tx for psoriasis?

Answer 9

Non-pharmacologic therapy -> used for all patients with psoriasis, regardless of disease severity

Pharmacologic therapy -> individualized to each patient

Question 10

How is a therapy selected?

Answer 10

Based on disease severity, presence or absence of comorbidities, and other special considerations (i.e., patient preferences, cost, hepatic or renal dysfunction).

Question 11

Tx for mild-moderate psoriasis?

Answer 11

Topical therapies -> 1st line recommendation

Question 12

Tx for mod-severe dx?

Answer 12

Phototherapy and photochemotherapy

Question 13

Extensive moderate to severe psorias tx?

Answer 13

1. Use systemic therapies ± topical therapies
2. Biologic agents

Question 14

Tx for controlled psoriasis?

Answer 14

Least potent, least toxic med

Question 15

What are the non-pharm tx for psoriasis?

Answer 15

1. Stress reduction
2. Skin moisturizers
3. Oatmeal baths
4. Skin protection
5. Avoidance of harsh soaps and detergents
6. Management of comorbidities (DLD, obesity, CVD)

Question 16

What is the fingertip unit method?

Answer 16

1 FTU = 500mg

Question 17

The selection of TCS formulation is based on what factors?

Answer 17

1. Assessment of dx severity
2. Dx location
3. Knowledge of patient preferences and age
4. Cost/insurance converage

Question 18

When would you use a lower potency TCS?

Answer 18

Infants and psoriatic lesions on face, intertriginous areas, or areas of thin skin

Question 19

When would you use mid-to-high potency TCS?

Answer 19

Initial therapy to use for other areas on body

Question 20

When would you use highest potency TCS?

Answer 20

reserve use for patients with thick plaques or recalcitrant disease

Question 21

Topical retinoids

CI

Answer 21

Pregnancy

Question 22

Calcipotriol

Counseling

Answer 22

1. Inactivated by ultraviolet A (UVA) light; apply after, NOT before UVA light exposure
2. Inactivated by acidic substances (i.e., salicylic acid); avoid concomitant use

Topical Vitamin D3 Analogs

Question 23

preferred regimen, when used in topical therapy?

Answer 23

Short-contact anthralin therapy (SCAT)

Question 24

Phototherapy & Photochemotherapy

Types, CI

Answer 24

Types:
* UV-A: PUVA
* narrow band UV-B: preferred (administered with coal tar (Goeckerman regimen) or anthralin (Ingram regimen)

CI: patients with history of melanoma or multiple non-melanoma skin cancers

Question 25

Salicylic acid | Counseling

Answer 25

1. Do NOT combine with ultraviolet B (UVB) phototherapy, as its filtering effect reduces UVB efficacy! 2. Do NOT use with calcipotriol, as it inactivates the vitamin D3 analog!

Question 26

Acitretin | CI, Warning, ADR, Monitoring

Answer 26

**CI:** Pregnancy, Methotrexate, Tetracyclines **Warnings:** Depression, photosensitivity, pseudotumor cerebri **ADR:** mucocutaneous effects **Monitoring:** pregnancy testing **Counseling:** Acitretin should NOT be used for women of child-bearing age UNLESS * Able/willing to use effective contraceptive during therapy duration (AND) at least 3 years after discontinuing the medication * Obtain two (2) negative pregnancy tests before initiating therapy, once monthly during therapy, and every three (3) months for three (3) years after discontinuing therapy * Avoid use of alcohol during therapy and for two (2) months after discontinuing therapy

Question 27

Cyclosporine | CI, ADR, Counseling

Answer 27

**CI:** Uncontrolled HTN **ADR:** nephrotoxicity, hypertension, hypertriglyceridemia, hyperkalemia **Counseling:** Do NOT administer with live vaccines

Question 28

Methotrexate | CI, Counseling

Answer 28

**CI:** pregancy, lacation **Counseling:** * Foilic acid supplementation * Screen high-risk patients for Hepatitis B and C before starting therapy. * Patients should use effective birth control for 3 months (males) and one (1) ovulatory cycle (females) after discontinuing therapy

Question 29

Tofacitinib | BBW, Warning, ADR, Monitoring, Counseling

Answer 29

**BBW:** ≥ 50 years old with ≥ 1 CV risk factor treated at higher doses **Warning:** Gi perforations **ADR:** Elevated BP and lipids **Monitoring:** Lipids, BP **Counseling:** Off-label for plaque psoriasis * Do NOT administer with biologic DMARDs, potent immunosuppressants, or live vaccines * Use caution in Asian patients due to increased frequency of side effects

Question 30

Apremilast | CI, Warning, ADR, Monitoring

Answer 30

**CI:** pregnancy, breastfeeding **Warning:** : GI effects (nausea, vomiting, diarrhea), weight loss, neuropsychiatric effects (depression, suicidal ideation, mood changes) **ADR:** severe nausea, vomiting & diarrhea, weight loss, depression, suicidal ideation **Monitoring:** signs & symptoms of depression, mood changes, suicidal thoughts **Counseling:** * Take medication with or without food. * Counsel patients that this medication should NOT be crushed, chewed, or split * dose titration to minimize GI effects * Requires titration is CrCl <30mL/min

Question 31

Route of admin for TNF-a inhibitors?

Answer 31

Intravenous (IV) --- infliximab Subcutaneous (SC) --- etanercept, adalimumab, certolizumab pegol

Question 32

Dosing frequency of TNF-a inhibitors?

Answer 32

Etanercept --- once weekly Adalimumab --- once every 2 weeks Certolizumab --- once every 2 weeks Infliximab --- once every 8 weeks

Question 33

TNF-a inhibitors | Warning, Monitoring, CI

Answer 33

**Warning:** HF **Monitoring:** Before therapy initiation: tuberculosis (TB) and hepatitis B screening **CI:** Do NOT administer with other biologic DMARDs or live vaccines

Question 34

For patients on infliximab therapy premidication?

Answer 34

antihistamines, acetaminophen, & corticosteroids to reduce risk of infusion reactions

Question 35

IL-12/IL-23 inhibitors | Brands, Monitoring, CI

Answer 35

Stelara (ustekinumab) **Monitoring:** screenings for hepatitis B, hepatitis C, TB, & HIV **CI:** Do NOT administer with live vaccines

Question 36

IL 17 Inhibitors | Brands, CI, Warning, Counseling

Answer 36

1. Cosentyx (secukinumab) 1. Taltz (ixekizumab) 1. Siliq (brodalumab) 1. Bimzelx (bimekizumab) **CI:** Chrohn's (brodalumab) **Warning** suicidal ideation (brodalumab, bimekizumab) **Counseling:** Do NOT administer with live vaccines * Use caution when using IL-17 inhibitors for patients with history of inflammatory bowel disease * Avoid use of brodalumab in patients with Crohn’s disease. * Black box warning for suicidal ideation (brodalumab)

Question 37

IL-23 inhibitors | Brand, Monitoring, Counseling

Answer 37

1. Tremfya (guselkumab) 2. Ilumya (tildrakizumab) 3. Skyrizi (risankizumab) **Monitoring:** screenings for hepatitis B, hepatitis C, TB & HIV **Counseling:** Do NOT administer with live vaccines!