Alternatives To Methotrexate For Psoriasis

When Would I Need A Biologic Dmard For Psoriatic Arthritis

Your doctor may suggest a biologic drug if you have severe disease or you havent responded to traditional DMARDs, Ostrowski says.

According to new guidelines for the treatment of psoriatic arthritis developed by the ACR and NPF, biologics should be one of the first line treatments for people with psoriatic arthritis. The British Society for Rheumatology states that a biologic may be considered if you have three or more sore joints despite having tried two or more nonbiologic DMARDs. Another reason to consider a biologic would be that youve tried one nonbiologic DMARD but still have five or more sore joints and are developing joint damage.

There are several types of biologics for psoriatic arthritis. A type of biologic called a TNF inhibitor targets a protein called tumor necrosis factor alpha thats associated with psoriasis and psoriatic arthritis. These include:

• Ustekinumab

Another type of biologic interferes with the activation of white blood cells called T cells, which prevents immune system reactions that cause inflammation. Abatacept is the only drug in this class.

Dosing of these drugs can vary from a self-administered injection under the skin once a week to once every few months. Another option is an intravenous infusion administered at a medical facility about once every two months.

New Drug Is Gamechanger In Psoriasis Treatment

A novel drug almost entirely cleared moderate to severe psoriasis in over 60% of the patients who took part in two phase three clinical trials of a new drug.

The University of Manchester andSalford Royal NHS Foundation Trustled studies on Bimekizumab , both published in the prestigious New England Journal of Medicine today, were funded byUCB Pharma the company that developed the treatment which could be available in as little as 12 months.

Given as an injection under the skin, Bimekizumab is a monoclonal antibody and the first to block both Interleukin 17A and Interleukin 17F which are overexpressed inpsoriasis.

Interleukin 17A and Interleukin 17F are two types of special proteins called cytokines which regulate the immune system. Other psoriasis drugs have only been able to block 17A.

One trial called BE RADIANT, compared the drug with Secukinumab, an IL17 A blocker:743 patients were enrolled and 373 patients were assigned to Bimekizumab

The BE SURE trial compared Bimekizumab withAdalimumab: of the478 patients enrolled, 319 patients were assigned to Bimekizumab.

Bimekizumab in both studies was given every 4 weeks for 16 weeks after which two maintenance schedules were possible: continue at every 4 weeks or go to an 8-week schedule .

Secukinumab and Adalimumab were given as per label.

The team assessed the efficacy of the treatments using thePsoriasis Area Severity Index with PASI 100 indicating clear skin.

More Fit Less Psoriasis

While some researchers focus their attention on coming up with new psoriasis treatments, others look at ways to avoid this skin disorder. One promising avenue of prevention centers on fitness.

Studies find that exercise, especially when itâs intense, might help reduce the chance of getting psoriasis. People who are less fit seem to have a higher risk for the disease. Although the link needs to be explored further, it may be about how exercise can lower chronic inflammation, a hallmark of psoriasis and many other conditions.

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Types Of Systemic Drugs

Retinoids. These are made from vitamin A and affect the way your skin cells grow and are shed. Most doctors prescribe one called acitretin .

If you have plaque psoriasis — inflamed, red skin with silvery scales — a retinoid works best when used with phototherapy. On its own, it works well to treat pustular psoriasis — a breakout of sore, red blisters or pus bumps — and erythrodermic psoriasis in which most of your skin looks very red and peels as if it’s burned.

This medication can cause serious birth defects even after you stop taking it. Don’t take it if youâre pregnant or plan to get pregnant within 3 years.

Methotrexate. This drug eases symptoms by curbing your immune system and slowing the growth of skin cells.

You take it once a week either by mouth or in a shot, and you should notice changes after 4 to 6 weeks. But this drug can have serious side effects. At first, you might have nausea or fatigue, and over time, it can damage your liver and blood cells.

Tell your doctor about any other health issues you have. Methotrexate isn’t safe for people who have anemia or liver disease. You should also watch how much alcohol you drink. Even one glass a day while you’re on it can cause liver problems. You’ll need regular blood tests so your doctor can check on your blood cells and liver. Youâll need to take it with daily folic acid to reduce side effects.

Both men and women should stop taking it if they plan to start a family.

Psoriasis Weight And Nutrition

No single diet or food will treat or prevent psoriasis. And you can get this condition at any size. Still, there are some signs that nutrition and weight do affect it — just as they affect many other conditions.

Body fat fuels inflammation. Doctors have known for a while that losing weight can reduce psoriasis symptoms and help your medicines work better at clearing your skin. The open question is: What’s the best way to lose weight?

In studies, people with psoriasis who trimmed off as little as 5% of their weight by following a low-calorie diet had clearer skin.

The traditional Mediterranean diet can also help lower inflammation, with foods like fish, fruit, vegetables, nuts, and olive oil. Researchers are looking at whether that might help make psoriasis less severe.

One small, short study offered a very low-calorie keto diet, followed by 6 weeks of a traditional Mediterranean diet. All the people in the study were overweight or obese and had psoriasis but werenât taking medication for it. They lost weight, and their psoriasis improved. Itâs not clear if that was because of the weight loss, the types of food they ate, or both things. More research will be needed to see exactly what worked.

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Data Items And Synthesis Of Results

Spreadsheets were established to capture both efficacy and safety outcomes . Incidence figures reported for the various AEs in each study were combined using a random effects model to allow for variability between studies. A random effects meta-analysis was performed on the incidence rates, yielding a pooled estimate of the mean incidence with 95% confidence interval and standard error. Handling of zeros: an incidence value of 0.5 was added in the case of a zero incidence. In addition, we also explored changing continuity correction of zeros to 0.1 from 0.5 but did not observe any notable difference in the overall results.

For the purpose of analysis AEs were classified into two groups: all AEs vs. treatment limiting AEs. Where an AE was not reported in a study, no imputation of data was made. Patient safety years were calculated for each study using the duration of methotrexate treatment and number of patients available within the studies. The total number of AEs, the total number of severe AEs, the number of AEs likely due to methotrexate treatment and also the number of deaths from each study were also captured. For meta-analysis of PASI75 outcomes in efficacy studies, a similar procedure using an Der-Simonian -Laird estimate was used to allow for calculation of mean AE rate in MTX-treated cohorts relative to patients allocated to placebo arms, followed by calculation of risk ratio between the two pooled estimates as reported in Results

Gut Bugs And Your Skin

You’re far from alone in your body. You share it with trillions of bacteria, fungi, and other tiny bugs, most of which live in your gut. Scientists call this miniature community the “microbiome.” This is natural, and having your inner environment in balance may be a key to good health.

Some of the bugs in your microbiome make fatty acids that control inflammation. . They also help to keep your immune system response under control. Researchers are now studying whether drugs made from helpful bacteria called probiotics might prove to be an effective psoriasis treatment.

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Complementary And Alternative Therapies

Mind-body therapies and stress management, including meditation and hypnosis, may help treat psoriasis. Studies show that people who practice meditation before getting light therapy do better than people who had light therapy alone. Exercise can help, too, as can drinking plenty of water.

Taking daily baths with lukewarm water and mild soap can help slough off scales. After your bath, gently pat skin dry and immediately apply a moisturizer to seal in water.

Talk to your doctor before taking any supplements or herbs, because some can have serious side effects or interact with common prescription medications, such as blood thinners and birth control pills. If you are pregnant or breastfeeding, ask your doctor before taking any supplement, herb, or over-the-counter medication. Be sure all your health care providers know about all therapies you use, including complementary and alternative therapies.

Nutrition and Supplements

DO NOT take vitamin A and D supplements. Both are used in prescription medications in high doses. Also, taking a supplement with your prescription medication could be dangerous if you get too much of these vitamins.

HerbsHomeopathyChiropractic

A few case studies have reported that spinal manipulation may reduce skin lesions in some people. Researchers do not know whether chiropractic care is helpful for all people with psoriasis.

Acupuncture

What Else Do I Need To Know About Biologics For Psoriatic Arthritis

Biologics are effective, but they increase your risk of infection, Ostrowski says.

If you develop an active infection while taking one of these drugs, you may need to stop treatment until you recover. Similarly, if you have active tuberculosis, hepatitis, or the human immunodeficiency virus , you will need to get the condition under control before starting biologic treatment.

If youve recently had cancer, you should discuss this with your rheumatologist and your oncologist before considering biologic treatment, Ostrowski advises.

Stay away from unpasteurized milk, raw meat, and raw eggs while taking these drugs to avoid catching a food-borne illness.

Also, women with psoriatic arthritis who are considering pregnancy and breastfeeding have additional things to consider. Many DMARDs, including biologics, cannot be used if youre pregnant or breastfeeding, Ostrowski says. If you may become pregnant, you need to discuss taking a biologic drug with your doctor first.

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What To Discuss With Your Dermatologist

Be sure to tell your dermatologist if you:

• Experience any health problem, even if it seems unrelated to taking methotrexate, such as fever, chills, body aches, bleeding, or bruising easily

• Become pregnant

• Feel uncertain about how to take methotrexate

• Think the information that came with the medicine about how to take methotrexate differs from what your dermatologist told you

Images

Cordoro KM. Management of childhood psoriasis. Adv Dermatol. 2008 24:125-69.

Feldman SR. Treatment of psoriasis. UpToDate 2015 Jul, Wolters Kluwer Health. Last accessed November 2015.

Hugh J, Van Voorhees AS, et al. From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies. J Am Acad Dermatol. 2014 70:168-77.

Menter A, Korman NJ, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis Section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol2009 61:451-85.

All content solely developed by the American Academy of Dermatology

The American Academy of Dermatology gratefully acknowledges the support from Bristol Myers Squibb.

Other Risks Of Apremilast

Other possible concerns related to the use of apremilast include:

• Weight loss. Apremilast can also cause unexplained weight loss. Your doctor should monitor your weight for unexplained weight loss during treatment.
• Effects with kidney disease. Talk to your doctor before taking this drug if you have kidney disease. You may need a different dosage.
• Drug interactions. You shouldnt combine apremilast with some other drugs, because they make apremilast less effective. Examples of these drugs include the seizure medications carbamazepine, phenytoin, and phenobarbital. Talk to your doctor about other medications youre taking before you start apremilast.

Systemic treatments also include injected prescription drugs. As with oral drugs, injected drugs called biologics work throughout your entire body to slow the diseases progress. Still other treatments include light therapy and topical medications.

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Efficacy Outcomes Of Mtx In Psoriasis

Despite the obvious limitations of limited study numbers, divergent study design, non-uniform outcome reporting, and small patient numbers, we performed a meta-analysis of treatment efficacy based on the only variable that was accessible across all studies analysed: the percentage of patients achieving 75% reduction of PASI from baseline . Fig 2 graphically summarises the PASI75 reported in the MTX-only treatment arm at 12 or 16 weeks, respectively, in each of the studies analysed. As evident from the figure, there is notable heterogeneity between studies . Dose range as underlying factor is unlikely, given that many studies employed a flexible dose increase scheme, covering a brought overall range . We were also unable to identify any other systematic potential causes, e.g. sample size, dosing scheme. Therefore, in the absence of any discernable factor accounting for heterogeneity, the figure displays a random effects model. The pooled PASI75 estimate calculated across all studies yielded at PASI75 of 45.2% compared to a calculated PASI75 of 4.4% for placebo . This yields a relative risk of 10.2 . Bearing in mind the caveats detailed above, we conclude that, across published MTX studies on psoriasis, approximately 40% of patients achieve PASI75 between weeks 1216.

Therapies Involving Biological And Biosimilars

In the same way as for rheumatoid arthritis, development of biologicals has been a groundbreaking event for the treatment of psoriasis, leading to unprecedented success in therapeutic approach of moderatetosevere forms of psoriasis and psoriatic arthritis. In that respect, even if not considered firstline treatments, biologic agents such as etanercept, adalimumab, infliximab and ustekinumab have been approved as secondline therapies for psoriasis, whereas golimumab has been approved for psoriatic arthritis therapy.

Clinical practice with biologicals has revealed their higher efficacy and tolerability in comparison to traditional systemic therapies , even in cases of refractory disease and expressly indicated for use in the socalled highneed patients, unresponsive or intolerant to all other available and approved systemic agents, MTX and cyclosporine included, or who cannot possible use such conventional systemic agents for reason of preexisting disease .

In addition, biologicals do not generally carry the same toxicity burden of toxic chemical or pharmacological adverse effects. Most related side effects are due to the specific biological properties of a given preparation, and result from neutralization of the biological activity of their target molecules, such as TNF or IL12/IL23.

Respective risk of the modified therapeutic effect is even greater in the case of biosimilars introduced as a de novo production line.

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Epsom Or Dead Sea Salt Baths

Bathing can help calm irritated skin and remove scales from your psoriasis plaques. Some people with psoriasis like to add Epsom or Dead Sea salts to their baths.

How It May Help:

The salts may help remove scales and ease itching.

How to Use It:

To try it, add a few teaspoons of bath salts to a warm bath and soak for 15 minutes. Make sure that your bath water is warm and not hot. Hot water can dry out your skin and make psoriasis worse. After youre done bathing, pat your skin dry and apply a moisturizer to lock in moisture.

What to Know:

Limit yourself to one bath or shower a day. Bathing more than that can irritate your skin.

Psoriasis And Oral Medications

Psoriasis is a common autoimmune disorder that causes red, thick, inflamed patches of skin. The patches are often covered in whitish silvery scales called plaques. In some cases, the affected skin will crack, bleed, or ooze. Many people feel burning, pain, and tenderness around the affected skin.

Psoriasis is a chronic condition. Even with treatment, psoriasis will never fully go away. Therefore, treatment aims to reduce symptoms and to help the disease enter remission. Remission is a period of little to no disease activity. This means there are fewer symptoms.

There are a range of treatment options available for psoriasis, including oral medications. Oral drugs are a form of systemic treatment, which means they affect your whole body. These drugs can be very strong, so doctors typically only prescribe them for severe psoriasis. In many cases, these drugs are reserved for people who havent had much success with other psoriasis treatments. Unfortunately, they can cause a variety of side effects and issues.

Read on to learn more about the most common oral medications and their side effects and risks.

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New Era Of Psoriasis Treatment

In the 1960s and ’70s, new info about how the immune system — your body’s defense against germs — plays a role in psoriasis led to several new treatments. Drugs like corticosteroids, cyclosporine, and methotrexate became mainstays for managing the disease. For the next few decades, though, advances in treatment slowed down.

Thanks to recent progress in research, that’s history.

Scientists studying other autoimmune diseases found new insights about the immune system. It turns out that some of the problems in those conditions are active in psoriasis, as well.

The new info brought treatments that target specific areas of your immune system. Called biologics, these drugs launched a new era of psoriasis treatment. New biologic therapies work well to treat psoriasis, and other new treatments are close to FDA approval.

Why Would I Need To Start Taking A Dmard Or Biologic For Psoriatic Arthritis

If you have a more aggressive form of psoriatic arthritis with multiple-joint involvement or involvement of your spine, the first DMARD to try is usually methotrexate, Dr. Ostrowski says. If you dont respond well to this medication or to one of the other traditional DMARDs, your doctor may suggest a biologic therapy.

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