JAMIE L. MCCONAHA, PHARMD, NCTTP, BCACP, CDE › › resource › resmg… · France NA 0.19% Italy NA 0.42% Germany NA 0.29% Finland 23.1 NA United States 7.2 0.16% Mexico NA

OVERVIEW OF PSORIATIC ARTHRITIS: CLINICAL CONSIDERATIONS FOR HEALTHCARE PROFESSIONALS

JAMIE L. MCCONAHA, PHARMD, NCTTP, BCACP, CDE

FACULTY DISCLOSURES

I have no conflicts of interest to disclose. I do not intend to discuss non-FDA approved drugs or investigational use of any product/device.

OBJECTIVES

Describe the epidemiology and pathophysiology of PsA

List the clinical features and manifestations of PsA that may aid in diagnosis and assessment of disease severity

Describe screening tools for patients suspected of having PsA

Discuss the importance of early detection of PsA and methods and tests used to diagnose the disease

Review treatment and management strategies for patients with PsA

PSORIATIC ARTHRITIS (PSA)

WHAT IS PSORIATIC ARTHRITIS?

Chronic, progressive, inflammatory arthritis

Considered a type of spondyloarthropathy

Swelling, stiffness, and pain in and around the joints, as well as overall fatigue

Early recognition, diagnosis and treatment is crucial to prevent permanent damage

INCIDENCE

Prevalence in patients with psoriasis ranges between 6-42%

Affects approximately 1% of the general population

Estimates vary due to delayed or missed diagnoses

Psoriatic arthritis. National Psoriasis Foundation. Available at:https://www.psoriasis.org/about-psoriatic-arthritis. Gelfand JM, et al. Epidemiology of psoriatic arthritis in the population of the United States. J Am Acad Dermatol. 2005. Mease PJ, Armstrong AW. Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis. Drugs. 2014.

EPIDEMIOLOGY

Affects both men and women equally

Usually occurs between 30-50 years, but can affect any age

Relationship to psoriasis (skin):

85% of patients present with skin psoriasis first

10-37% have skin and joint disease simultaneously

6-18% have arthritis preceding psoriasis

Liu JT, Yeh, HM, Liu SY, Chen KT. Psoriatic arthritis: epidemiology, diagnosis, and treatment. World J Orthop. 2014. Sep 18; 5(4):537-543.

INCIDENCE AND PREVALENCE COMPARISON

Country Incidence (1/100000) Prevalence

China NA 0.02%

Japan 0.1 0.001%

Greece 3 0.17%

France NA 0.19%

Italy NA 0.42%

Germany NA 0.29%

Finland 23.1 NA

United States 7.2 0.16%

Mexico NA 0.02%

Liu JT, Yeh, HM, Liu SY, Chen KT. Psoriatic arthritis: epidemiology, diagnosis, and treatment. World J Orthop. 2014. Sep 18; 5(4):537-543.

PATHOPHYSIOLOGY

Exact cause is unknown

Complex interplay of genetic, environmental, and immunologic factors

Genetics: strong familial association

Environmental: may trigger immune response (viruses or physical trauma)

Immunologic: activated T cells in joint tissue; TNF-α guides inflammatory process

Husni ME. Psoriatic arthritis. Cleveland Clinic. Oct 2016. FitzGerald O, Winchester R. Psoriatic arthritis: from pathogenesis to therapy. Arthritis Res Ther. 2009; 11(1): 214.

COMORBID CONDITIONS

Psoriasis and psoriatic arthritis comorbidities:

Cancer

Cardiovascular disease

Crohn’s Disease

Depression

Diabetes

Metabolic syndrome

Obesity

Osteoporosis

Uveitis

Liver disease

Treatment of the underlying condition (psoriasis/arthritis) often alleviates comorbid condition symptoms or reduces risk

National Psoriasis Foundation. Comorbidities associated with psoriatic arthritis. https://www.psoriasis.org/about-psoriasis/related-conditions

SIGNS AND SYMPTOMS

Painful, swollen joints

Stiffness

Dactylitis (sausage-like swelling)

Enthesitis (tendon or ligament pain)

Nail and skin changes

Fatigue

SIGNS AND SYMPTOMS

http://www.discoverpsa.com/

Back Involvement (40%)

DIP involvement (39%)

Nail psoriasis (67%)

Enthesopathy (38%)

Dactylitis (48%)

SIGNS AND SYMPTOMS

Many patients experience nonspecific musculoskeletal symptoms before diagnosis

In a 2017 study by Eder et al, the following preclinical symptoms predicted the development of psoriatic arthritis:

Arthralgia in women (hazard ratio [HR] 2.59, P=0.02)

Heel pain (HR 4.18, P=0.02)

High fatigue score (HR 2.36, P=0.007)

High stiffness score (HR 2.03, P=0.045)

Eder L, et al. The development of psoriatic arthritis in patients with psoriasis is preceded by a period of nonspecific musculoskeletal symptoms: a prospective cohort study. Arthritis Rheumatol. 2017; Mar. 69(3):622-629.

PSORIATIC ARTHRITIS VS RHEUMATOID ARTHRITIS

PsA RA

Sex Distribution Males = Females Females > Males

Symptoms Swelling, pain and stiffness

Swelling, pain and stiffness

Joint Involvement Ray pattern distribution Symmetrical distribution

Extra-Articular Manifestations

Rheumatoid nodules absent

Rheumatoid nodules present

Nail involvement ~20 nail pits Absent

Blood Tests Seronegative Seropositive

Gladman DD, et al. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005; 64(Suppl II).

DIAGNOSIS

Imaging

X-Rays: Pinpoint changes in the affected joints

CT or MRI: Identify changes in tendons or ligaments or otherwise more detailed examination of joints

Laboratory

Rheumatoid Factor (RF): Usually absent in psoriatic arthritis

Synovial Fluid: Aspiration and examination of synovial fluid of an affected joint revealing uric acid crystals to rule out gout

There is no single test to confirm a psoriatic arthritis diagnosis.

CLASSIFICATION OF PSORIATIC ARTHRITIS

Moll and Wright Classification Criteria for PsA

Proposed in 1973

Oldest and best-known

Simple to use diagnostic criteria

Inflammatory arthritis (peripheral arthritis and/or sacroiliitis or spondylitis)

Presence of psoriasis

Absence of serological tests for rheumatoid factor

Classifies patients with PsA into 5 subgroups

Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis. 2005; 64(Suppl II).

MOLL AND WRIGHT CLASSIFICATION SYSTEM

5 subgroups:

Polyarticular, symmetric arthritis

Oligoarticular and asymmetric

Distal interphalangeal joint (DIP) predominant

Spondylitis predominant

Arthritis mutilans

https://psoriatic-arthritis.com/diagnostic-criteria/

CLASSIFICATION OF PSORIATIC ARTHRITIS (CASPAR)

Patient must have inflammatory articular disease (joint, spine, or entheseal) and >3 points

Category Description Points

Current psoriasis or Personal or family history of psoriasis

Current psoriasis: skin or plaque disease confirmed by a rheumatologist or dermatologist Family history: in 1st or 2nd degree relative

2 (current) or 1 (history)

Nail psoriasis Onycholysis, pitting, or hyperkeratosis

1

Negative rheumatoid factor 1

Dactylitis (current or history) Swelling of entire digit 1

Radiographic evidence of periarticular new bone formation

Found on x-rays of hand or foot (excludes osteophytes)

1

https://www.hopkinsarthritis.org/arthritis-info/psoriatic-arthritis/diagnosis/

CASE STUDY: CLASSIFICATION


Kim is a 38 year old white woman you have treated in your practice for five years. Kim has a 3-year history of mild scalp psoriasis but is an otherwise healthy mother of two who works as an attorney. At the end of her most recent annual physical, she mentions she has been experiencing intermittent low back and right sided hip pain with difficulty bending over when picking up her kids or cleaning around the house. Kim notes that the pain began about six months ago without injury and comes and goes without any obvious trigger, although the pain seems to be worse when she gets up in the morning. Kim states that she thinks it is normal “wear and tear” from years of running and standing long periods in court, but would like to know if there are any at-home or OTC remedies she can take when the pain begins. She denies fever, swelling and pain in other joints or worsening of her scalp psoriasis.

Clinical case: psoriatic arthritis. American College of Rheumatology.


Moll and Wright

Psoriasis

(-) RF

Inflammatory arthritis

Meets 1 of 5 subgroup types

Polyarticular, symmetric arthritis

Oligoarticular and asymmetric

Distal interphalangeal joint predominant (DIP)

Spondylitis predominant

Arthritis mutilans

CASPAR

Inflammatory articular disease

Current psoriasis (2)

Nail psoriasis (0)

Negative rheumatoid factor (1)

Dactylitis (0)

Radiographic evidence (0)

ASSESSMENT OF PSA

ASSESSMENT OF PSA

Requires consideration of all major disease domains

Peripheral arthritis

Axial disease

Enthesitis

Dactylitis

Psoriasis

Nail disease

Impact of disease on quality of life

Structural damage

Relevant comorbidities

PSORIASIS ASSESSMENT (SKIN)

General Principles

Body surface area (BSA) involvement

Palm size = 1% BSA

Rule of Tens

Handprint = 1% BSA

Assessment Methods

Psoriasis Area and Severity Index (PASI)

Physician Global Assessment (PGA)

ACR JOINT COUNT

American College of Rheumatology (ACR) uses joint counts in assessment of rheumatoid arthritis

Several types of joint count methods:

66/68 Joint Count

Ritchie Articular Index

Thompson-Kirwan Index

44-Swollen Joint Count

28-Joint Count

ACR JOINT COUNT

Stekhoven D, et al. Hypothesis-free analysis from a large psoriatic arthritis cohort support merger to consolidated peripheral arthritis definition without subtyping. Clinical Rheumatology. 2017; 36(9):2035-2043.

JOINT COUNTS IN PSA

ACR Joint Counts originally developed for RA

Limitations to use for patients with PsA

Modified ACR Count developed for PsA

Reproducibility verified by studies

Not tested specifically for sensitivity to change over time

Miedany Y. Recent developments in management of psoriatic arthritis. Current Rheumatology Reviews. 2005; 1:9-19.

DISEASE ACTIVITY INDEX FOR PSORIATIC ARTHRITIS (DAPSA)

Originally developed for reactive arthritis

Validated for use in PsA

Assesses 5 variables:

Tender and swollen joints

Patient pain assessment (PPA) and patient global assessment (PtGA)

Serum acute-phase response (c-reactive protein)

https://rheuma.charite.de/fileadmin/user_upload/microsites/ohne_AZ/m_cc13/rheuma/Templates/DAPSA_ENG.pdf

QUALITY OF LIFE ASSESSMENT

Important to assess the impact of disease on patient’s quality of life

Physical function

Participation

Measure of improvement in these areas with treatment

Many different scales to assess

Medical Outcomes Study Short Form 36 (SF-36)

Arthritis Impact Measurement Scales (AIMS and AIMS2)

Psoriatic Arthritis Quality of Life (PsAQoL)

Mease PJ. Psoriatic arthritis assessment tools in clinical trials. Ann Rheum Dis. 2005;64 (Suppl III):ii49-ii54.

ADDITIONAL ASSESSMENT TOOLS

Psoriatic Arthritis Screening and Evaluation (PASE)

Psoriasis Epidemiology Screening Tool (PEST)

Toronto Psoriatic Arthritis Screening Tool (ToPAS)

Early Arthritis for Psoriatic Patients Questionnaire (EARP)

PROGRESSION TO SEVERE DISEASE

The following factors indicate a higher likelihood of severe disease:

5+ swollen joints

Elevated acute-phase reactants

High medication use

Poor response to initial treatment

Radiologic evidence of bone erosion

PsA-related disability

MINIMAL DISEASE ACTIVITY (MDA)

5 out of 7 Criteria Met = MDA

Health Assessment Questionnaire <0.5

Swollen joint count <1

Tender joint count <1

Tender entheseal joints <1

PASI / BSA <1 or < 3

Patient assessment of pain on VAS <15

Patient global activity on VAS <20

Coates LC, Fransen J, Helliwell PS. Ann Rheum Dis. 2010 Jan; 69(1): 48-53.

PSORIATIC ARTHRITIS GUIDELINES

PSORIATIC ARTHRITIS GUIDELINES

American College of Rheumatology and National Psoriasis Foundation Clinical Practice Guidelines • Currently under peer review • Anticipated 2018 release European League Against Rheumatism (EULAR): Recommendations for Management of Psoriatic Arthritis with Pharmacologic Therapies • 2015 update

https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Psoriatic-Arthritis

GOALS OF TREATMENT

Reduction of pain

Improvements in the other signs and symptoms of disease (including skin and nail involvement)

Optimization of functional capacity and quality of life

Inhibition of the progression of joint damage

Coates LC, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 treatment recommendations for psoriatic arthritis. Arthritis & Rheumatology 2016; 68(5):1060-1071.

Figure reprinted with permission from Oxford University Press.

TREATMENT OPTIONS

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Corticosteroids

Traditional disease-modifying antirheumatic drugs (DMARDs) (oral agents)

Biologics

PDE-4 Inhibitor

JAK Inhibitor

Complementary and alternative medicine (CAM)

NSAIDS

Nonsteroidal Anti-Inflammatory Drugs

Available over-the-counter and by prescription

Alleviate joint symptoms

Examples:

Ibuprofen

Naproxen sodium

Sulindac

Indomethacin

Etodolac

Arachidonic Acid

COX-1

Cytoprotective prostaglandins (platelet aggregation, GI mucosal integrity, renal

function)

COX-2

Inflammatory prostaglandins (pain, inflammation, mitosis,

growth)

NSAID SELECTIVITY

Nonselective COX-1 and COX-2 Inhibitors

Preferential COX-2 Inhibitors

Selective COX-2 Inhibitors

Aspirin Meloxicam Celecoxib

Ibuprofen Etodolac

Diclofenac

Ketoprofen

Indomethacin

Naproxen



NSAID ADVERSE EFFECTS

Worsening of psoriatic skin lesions

Adverse effects by organ system:

Cardiovascular risk

Gastrointestinal

Renal

Central nervous system

CORTICOSTEROIDS

CORTICOSTEROIDS

MOA:

Provide relief from pain and stiffness by reducing inflammation

Glucocorticoids ------- >PLA2-------- >Eicosanoid + PAF synthesis

Prostaglandins Leukotrienes

The main mediators of pain and inflammation

CORTICOSTEROIDS

Corticosteroids are available in various formulations

Topical: 1st line treatment for skin psoriasis

Oral: not used for skin lesions; conditionally recommended for PsA

Injectable: used for mild PsA (minimal joints)



CORTICOSTEROID INJECTIONS

Periodic intra-articular injections can be used as 1st line as adjunct to NSAIDs

Mild peripheral disease, dactylitis, and enthesitis

Never used as monotherapy

Sometimes used as bridge therapy while DMARD is instituted or in case of acute flare-ups

Administered by a physician

Examples include:

Prednisone

Cortisone

Dexamethasone

Coates LC, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 treatment recommendations for psoriatic arthritis. Arthritis & Rheumatology 2016; 68(5):1060-1071. Gossec L, Smolen JS, Gaujoux-Viala C, et al. European League against Rheumatism European league against rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. Ann Rheum Dis. 2012;71(1):4–12.

CORTICOSTEROIDS

Provide relief from pain and stiffness by reducing inflammation

Long-term use should be avoided due to high risk of adverse effects

Psychosis

Retention of fluid/edema/hypertension

Weight gain

Peptic ulcer disease (PUD)

Infection

Osteoporosis

Gossec L, Smolen JS, Gaujoux-Viala C, et al. European League against Rheumatism European league against rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. Ann Rheum Dis. 2012;71(1):4–12.

TRADITIONAL DMARDS

Disease-Modifying Anti-Rheumatic Drugs

Available by prescription only

Induce remission of disease

Examples include:

Methotrexate

Leflunomide

Sulfasalazine

Cyclosporine

Antimalarial drugs

METHOTREXATE (MTX)

MOA:

Dosing:

Initial: 2.5-5mg test dose

Weekly: 7.5-25mg

Folate supplementation

1-5mg/day except on days of MTX

Adverse effects:

GI (vomiting, diarrhea, stomatitis)

Mucosal ulcers

Hepatotoxicity

Thrombocytopenia

Pulmonary toxicity

Contraindications:

Chronic liver disease

Immunocompromised

Preexisting blood disorders

Pregnant/nursing

Competitively inhibits dihydrofolate reductase

Reduces synthesis of folate cofactors

Reduces production of nucleic acids

responsible for cell division and proliferation

METHOTREXATE: MONITORING

CBC with differential and platelets

Baseline

7 to 14 days after initiating therapy or dose increase

Every 2 to 4 weeks for first few months

Every 1 to 3 months depending on leukocyte count and stability of patient

BUN and serum creatinine

Baseline and every 2 to 3 months

Calculate glomerular filtration rate if at risk for renal dysfunction

LFTs

Baseline

Monthly for first 6 months

Every 1 to 2 months

Pregnancy test

Chest x-ray and pulmonary function test

Lexi-Drugs (Methotrexate) Lexicomp Online. Hudson, OH: Lexicomp, Inc. Accessed August 9, 2018.

LEFLUNOMIDE

Prodrug that is metabolized into a pyrimidine synthesis inhibitor

T-cell anti-inflammatory effect in vivo

Dosing: 20mg QD

Patient response seen within 1 month

Jones P, White D. Reappraisal of the clinical use of leflunomide in rheumatoid arthritis and psoriatic arthritis. Open Access Rheumatol. 2010;2:53-71.

LEFLUNOMIDE + METHOTREXATE

In patients with RA who were resistant to methotrexate, leflunomide therapy may be added

Different, but complementary, mechanisms of action

Requires careful monitoring of liver function tests

LEFLUNOMIDE ADVERSE EFFECTS

Diarrhea

Hepatotoxicity

Anaphylaxis

Teratogen (possible carcinogen)

Pregnancy-absolute contraindication

SULFASALAZINE

Prodrug converted to sulfapyridine + 5-aminosalicyclic acid in the colon by enteric bacteria

Mechanism of action unknown, but thought to function as an anti-inflammatory agent

Dose:

Initial: 500 mg QD

Maintenance: 2-3 g daily in divided doses

Patient response seen within a month; may take up to 12 weeks in some patients

SULFASALAZINE ADVERSE EFFECTS

Nausea and vomiting

Hypersensitivity

Renal dysfunction

Anemia

Infertility (male)

Photosensitivity

May make urine/skin yellow

CYCLOSPORINE

MOA: suppresses IL-2 and TNF inflammatory actions of T-cells

A last resort DMARD

Effective for peripheral arthritis, axial involvement, and skin lesions

2 most serious side effects:

Nephrotoxicity

Hypertension

ANTIMALARIAL AGENTS

Not FDA-approved for use in PsA

May be beneficial to treat joint inflammation due to additional MOA aside from interfering with malarial parasites

Inhibition of transportation of neutrophils and chemotaxis of eosinophils

Reports of favorable responses have been offset by the worsening of skin disease

Efficacy and safety not yet established in PsA

Future possibilities:

Hydroxychloroquine

Chloroquine phosphate

Nash P, Clegg DO. Psoriatic arthritis therapy: NSAIDs and traditional DMARDs. Annals of the Rheumatic Diseases 2005;64(Suppl II):ii74-ii77.doi: 10.1136/ard.2004.030783



TRADITIONAL DMARDS-PLACE IN THERAPY

Traditional DMARDs are indicated for moderate-to-severe disease within multiple domains of psoriatic arthritis

Peripheral arthritis (first line)

Dactylitis (second line)

Typically indicated once a patient has insufficient response to NSAIDs and/or local glucocorticoid injections

BIOLOGIC DMARDS

TNF-Inhibitors

T-cell (T-lymphocyte) blockers

Interleukin blockers

JAK inhibitors

BIOLOGIC DMARDS: TNF-INHIBITORS

TNF-ΑLPHA INHIBITORS

Etanercept

Infliximab

Adalimumab

Golimumab

Certolizumab pegol

TNF-ALPHA INHIBITORS

MOA:

TNF-α is a protein expressed on the surface of macrophages, T-lymphocytes, natural killer cells, smooth muscle cells, and fibroblasts

It is a proinflammatory cytokine implicated in the pathogenesis of many diseases, such as rheumatoid arthritis, inflammatory bowel disease, and ankylosing spondylitis

Reduction of TNF-α leads to reduced chronic inflammatory responses in these diseases

Tauseef A, et al. Clinical use of anti-TNF therapy and increased risk of infections. Drug Health Patient Saf. 2013;5:79-99.

TNF-INHIBITORS: GENERAL PRINCIPLES

Contraindicated in patients with active, serious infections

PPD testing should be performed on all patients

Do not give live vaccines

Do not use in patients with multiple sclerosis (MS) or demyelinating diseases

Caution in patients with heart failure

Screening for hepatitis B infection when appropriate

ETANERCEPT

MOA: binds to TNF-α and blocks interaction with cell surface receptors

Dose: 50mg subQ once weekly

Off-label: 25mg twice weekly

Biosimilar: Etanercept-szzs

ETANERCEPT ADMINISTRATION

http://pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-com/enbrel/enbrel_piu.ashx

INFLIXIMAB

MOA: binds to both the soluble and transmembrane TNF-α molecules, thereby neutralizing the effects of TNF-α

Dose:

IV 5mg/kg at 0, 2, and 6 weeks, followed by 3mg/kg every 8 weeks thereafter

Often given in combination with methotrexate

Biosimilars:

Infliximab-dyyb

Infliximab-qbtx

Infliximab-abda

ADALIMUMAB

MOA: binds to TNF-α

Interferes with binding to TNF-α receptor sites and subsequently cytokine-driven inflammatory processes

Dosing: 40mg subQ every other week

May continue methotrexate, other nonbiologic DMARDs, corticosteroids, NSAIDs, and/or analgesics

Biosimilars:

Adalimumab-atto

Adalimumab-adbm

ADALIMUMAB: ADMINISTRATION

http://www.rxabbvie.com/pdf/humirapen_PIL.pdf

GOLIMUMAB

MOA: binds to TNF-α, thus interfering with endogenous TNF-α activity

Dose:

IV Golimumab: 2 mg/kg at weeks 0, 4, and then every 8 weeks thereafter

SubQ Golimumab: 50mg once a month

Used alone or in combination with methotrexate or other nonbiologic DMARDs

CERTOLIZUMAB PEGOL

MOA: binds to and selectively inhibits TNF-α activity

Dose: SubQ

400mg (given as 2 injections of 200mg each)

Repeat dose 2 and 4 weeks after initial dose

Maintenance: 200mg every 2 weeks or 400mg every 4 weeks

BIOLOGIC DMARDS: T-CELL BLOCKERS

Abatacept

ABATACEPT

MOA: inhibits T-cell (T-lymphocyte) activation by binding to antigen presenting cells (APC), thus blocking the interaction between the two

Activated T-lymphocytes are found in the synovium

Without Abatacept With Abatacept

Illustrating drug binding to CD80/86 and blocking CD28 from binding

ABATACEPT

Dose:

IV: dosed based on body weight; initial infusion followed by repeat infusions at 2 and 4 weeks, then every 4 weeks thereafter

SubQ: 125mg once weekly

Given alone or in combination with nonbiologic DMARDs

BIOLOGIC DMARDS: INTERLEUKIN BLOCKERS

INTERLEUKIN BLOCKERS

Ustekinumab

Secukinumab

Ixekizumab

INTERLEUKIN BLOCKERS

USTEKINUMAB

MOA: inhibits IL-12 and IL-23

Dose:

45mg subQ at 0 and 4 weeks, then every 12 weeks thereafter

Similar to TNF-inhibitors, serious infections remain a concern

USTEKINUMAB: MONITORING/ADVERSE EFFECTS

Development of malignancies (1.3%)

Monitor at-risk patients for non-melanoma skin cancer

Other adverse effects include injection site reactions, headache and fatigue

Avoid live vaccines

SECUKINUMAB

MOA: selectively binds to IL-17

Dose:

With loading dose: 150mg subQ at weeks 0, 1, 2, 3, and 4 followed by 150mg every 4 weeks

Without loading dose: 150mg subQ every 4 weeks

IXEKIZUMAB

MOA: selectively binds to IL-17A

Dose: 160mg subQ given once, followed by 80mg every 4 weeks

*for patients with coexisting moderate-to-severe plaque psoriasis, the dosing schedule for plaque psoriasis is used

PDE-4 INHIBITOR

APREMILAST

Phosphodiesterase 4 (PDE-4) inhibitor

MOA:

PDE-4 regulates the conversion of cAMP AMP

Inhibition of PDE-4 allows for increased levels of cAMP

This results in decreased production of pro-inflammatory cytokines and increased production of anti-inflammatory mediators

Targeted synthetic DMARD

APREMILAST

Used in the treatment of peripheral disease as well as dactylitis and enthesitis

Limited to patients who have failed NSAIDs, corticosteroids, and both the traditional and biologic DMARDs

Dose: 30mg BID

APREMILAST ADVERSE EFFECTS

Depression

Weight loss

Diarrhea

Headache



JAK INHIBITOR

TOFACITINIB

MOA: inhibits JAK enzymes

Inhibition of these enzymes affects the signaling of multiple cytokines involved in inflammation

Dose:

Immediate release: 5mg BID

Extended release: 11mg QD

May use in combination with nonbiologic DMARDs

TOFACITINIB ADVERSE EFFECTS

Serious infections

Herpes zoster (shingles)

Infections in patients with diabetes

Cancer and immune system problems

Tears in stomach or intestines

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)


The National Center for Complementary and Alternative Medicine (NCCAM) and The National Center for Health Statistics (part of the CDC) show that more than 1/3 of Americans use complementary and alternative medicine

Evidence support for CAM use in psoriatic arthritis is anecdotal

Options:

Diet and Nutrition

Herbal Remedies

Mind/Body Therapies

Alternative Therapies

Exercise (including Yoga & Tai Chi)

Complementary and Alternative Therapies. National Psoriasis Foundation. 2018. Accessed August 14, 2018.


Diet and Nutrition

Reduce alcohol, gluten, and nightshades

Add fish oil, vegetables, and vitamin D

Special diets:

Pagano

Vegan

Paleo

Herbal Remedies

Aloe Vera

Apple Cider Vinegar

Capsaicin

Tea Tree Oil

Turmeric

Mind/Body Therapies

Aromatherapy

Chamomile, Tea Tree, Rose, Lavender

Meditation

Mindfulness

Spa therapy

Alternative Therapies

Acupuncture

Acupressure

Massage

Exercise

Yoga

Tai Chi

SUMMARY

Psoriatic arthritis is a chronic, progressive type of inflammatory arthritis

Patients with psoriatic skin disease should be assessed for symptoms of psoriatic arthritis

Symptoms may include pain, stiffness and tenderness in the joints, as well as dactylitis, enthesitis, and nail changes

Treatment options include NSAIDs, corticosteroids, oral DMARDs, biologics, PDE-4 inhibitors, and JAK inhibitors

THANK YOU!

Jamie L. McConaha, PharmD

[email protected]

mailto:[email protected]

Documents

JAMIE L. MCCONAHA, PHARMD, NCTTP, BCACP, CDE › › resource › resmg… · France NA 0.19% Italy NA 0.42% Germany NA 0.29% Finland 23.1 NA United States 7.2 0.16% Mexico NA