Alternative And Complementary Therapies
More than 70% of Canadians regularly use alternative and complementary therapies such as vitamins and minerals, herbal products, homeopathic medicines and other natural health products to stay healthy and improve their quality of life1. Talk to your doctor about complementary therapies that may be right for you.
Healthy Diet: Many scientific studies have shown that a balanced, low-fat diet can improve your health and prevent many serious illnesses. Healthy eating can also improve your general well-being. Some experts believe that psoriasis may cause nutritional deficiencies in protein, folates , water and calories. Correcting deficiencies may help to improve your overall health.
Acupuncture: There is no scientific evidence to recommend the use of acupuncture for psoriasis, and its effectiveness has not been proven in clinical studies. If you go this route, choose your practitioner carefully. Look for a trained, certified acupuncturist. Make sure that only sterile, single-use needles are used to avoid the risk of transmittable infectious diseases, such as hepatitis or HIV.
What To Discuss With Your Dermatologist
You should tell your dermatologist if you:
Have any side effects while taking the biologic
Stop taking the biologic
Have questions, including how to take the biologic
Biologics and vaccines
Before you get a flu shot or vaccinated against any disease, call your dermatologist. You should NOT get some vaccines while taking a biologic.
Related AAD resources
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.
Kim WB, Marinas JEC, et al. Adverse events resulting in withdrawal of biologic therapy for psoriasis in real-world clinical practice: A Canadian multicenter retrospective study. J Am Acad Dermatol 2015 73:237-41.
Motaparthi K, Stanisic V, et al. From the Medical Board of the National Psoriasis Foundation: Recommendations for screening for hepatitis B infection prior to initiating antietumor necrosis factor-alfa inhibitors or other immunosuppressive agents in patients with psoriasis. J Am Acad Dermatol. 2014 Jan 70:178-86.
Singh JA, Wells GA, et al. Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD008794. DOI: 10.1002/14651858.CD008794.pub2.
All content solely developed by the American Academy of Dermatology
The American Academy of Dermatology gratefully acknowledges the support from Amgen and .
How Biologic Drugs Are Administered
Biologic treatments are administered by injection or IV infusion because they consist of large molecules that cannot be properly absorbed orally. The compounds are also complex and fragile, making them unstable in the gastrointestinal system.
Injection or infusion, depending on the specific drug, can be administered in a clinical setting. Many biologic drugs that can be absorbed under the skin, or subcutaneously, can also be self-injected at home.
Researchers are aiming to develop drugs that work like biologics, but which could potentially be taken orally, Dr. Kimball said. We still have areas of research for oral treatments that are potentially more convenient and maybe less expensive over time, she explained. So there’s some good work going on and some new approaches there.
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When Are Biologic Therapies Used Am I A Good Candidate
Many treatments for psoriasis are geared toward managing the skin or joint symptoms. However, biologics additionally work to address the underlying causes of psoriasis inflammation. In doing so, they can decrease a patients overall inflammatory load and improve comorbid conditions which can arise in psoriasis, including increased risk of heart attack, stroke, kidney/liver damage, etc. If patients struggle to achieve and maintain clearance with other topical psoriasis treatments, biologics are a good option. Side effects are uncommon on patients treated with biologics, but they can occur. We work with patients to ensure their psoriasis is managed safely and effectively.
Biologic drugs may be effective therapies for individuals with moderate to severe psoriasis who arent managed effectively with other treatments. Consider your answers to the following questions when determining whether or not biologic therapy is right for you:
Barriers To Widespread Use
When biologics first came on the scene, guidelines called for starting with older and less-expensive disease-modifying drugs, such as methotrexate and cyclosporine, but now doctors are increasingly starting biologics earlier when and where they can.
The main impediment? Cost.
Access to biologics has been impeded by the high costs of these drugs. Some insurers require that you tryand failother therapies before starting on a biologic for your psoriasis. This is known as step therapy, and it is meant to rein in costs.
Access is not bad, says Dr. Strober. However, the prior authorization work needed to deliver the drugs and imposed on a busy practice is onerous.
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Biologic Treatments Used In Dermatology
Biologics are medications made from human or animal proteins. They are designed to specifically target biologic pathways that cause inflammation in the skin and other organs.
Biologics have been used in many people worldwide to treat severe psoriasis, psoriatic arthritis, other types of arthritis and inflammatory bowel diseases . Biologic medications are given as injections.
A condition such as psoriasis develops in people who are genetically predisposed. Immune cells are triggered and become overactive, creating inflammation in the skin and, in some cases, the joints . Biologics work in different ways to traditional treatments by blocking the activation and behaviour of immune cells that play a role in a disease such as psoriasis. Examples of biologic drugs currently used in Australia to treat psoriasis include etanercept , adalimumab , infliximab , ustekinumab and secukinumab .
It is important to remember that all systemic medications, whether traditional or the newer biologics, have broad effects and people undergoing treatment have to be carefully monitored.
Biologics are very expensive. In Australia they are available on the Pharmaceutical Benefits Scheme only after all the more commonly prescribed treatments have been tried and shown to be ineffective or cannot be used in in a particular person due to side effects.
This information has been written by Dr Pam Brown
There Are Many Drug Options For Managing Active Psa Heres What Happened When A Study Compared Them With Each Other
New psoriatic arthritis treatment guidelines from the American College of Rheumatology say that most people with active psoriatic arthritis should choose an anti-TNF drug, such as adalimumab or infliximab , as their first line of therapy.
If a patient doesnt respond well to one or more of these drugs or cant take them for some reason, they might then consider a newer type of biologic an interleukin inhibitor like ustekinumab or secukinumab .
Although interleukin inhibitors have also been proven to help patients with psoriatic arthritis, there havent been many large studies directly measuring them against anti-TNF drugs.
A new study published in the Journal of Rheumatology aimed to compare these classes of medication in terms of how well they work for two specific complications of psoriatic arthritis: enthesitis and dactylitis .
This study, a literature review that analyzed data from 18 previous trials, included information on a total of nearly 7,000 psoriatic arthritis patients who had enthesitis and dactylitis. Researchers determined that both types of drugs beat out placebos and that they worked equally well for PsA patients with enthesitis and dactylitis.
After 24 weeks, the anti-TNF drugs demonstrated significant resolution of these complications, the authors reported. The two classes also worked similarly in terms of improving disease activity scores as well as quality of life scores.
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Sticking To Your Treatment Plan
Treating PsA takes a lot of work, and it can be hard to keep up with all the aspects of your care. The Psoriasis Foundation says the main reason PsA treatments fail is that people don’t stick to them properly.
Biologic therapy comes with some challenges, including high costs, fear of side effects, not feeling better quickly enough, or the timing of treatment might be inconvenient. It is also not uncommon for people to feel wary of biologics.
But your healthcare provider has prescribed biologic drug therapy because they have determined the benefits outweigh the risks. And, fortunately, most of the newer biologics are effective and safe to use.
Stopping treatment, regardless of the reason, is never a good idea. You will likely find yourself with increased PsA symptoms and flares as soon as you stop using your biologic or other treatments. The decision to stop or reduce treatment should be made between you and your provider.
Have A Worry Or Phobia Youre Not Alone
Biologics target specific parts of the immune system. They treat diseases by modulating activity of specific immune cells or inflammatory messengers called cytokines.
Since biologics are so targeted, they can also be safer than medications that broadly suppress the immune system.
As we continue to gain knowledge about the specific causes of diseases such as psoriasis, better and safer biologics will continue to come onto the market.
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Table 2 How And When To Take A Biologic Drug
|Drug name||How the drug is given||How often|
|Adalimumab||Under the skin||
Psoriasis: Two injections the first week, followed by another injection the second week. Every other week after.
Psoriatic arthritis: Every other week.
Psoriasis: Twice weekly for 3 months, followed by once weekly.
Psoriatic arthritis: Once weekly.
|Given in weeks 0, 2, and 6, then every 8 weeks.|
|Ustekinumab||Under the skin||Two injections separated by 4 weeks repeat treatment every 12 weeks.|
Some of the biologics have multiple uses and are also approved for treating other diseases such as ankylosing spondylitis, Crohns disease, rheumatoid arthritis, ulcerative colitis, and other autoimmune diseases.
What Makes Someone A Candidate For Biologics And Who Should Avoid Them
Biologics are appropriate for people with moderate to severe psoriasis. In some cases, this refers to psoriasis that affects more than 10% of the bodys surface area.
People with psoriasis that affects less of the skin may still receive biologics. The affected areas may be unique and significant for example, psoriasis affecting the hands can be debilitating, even though it only covers a small percent of the total body surface area.
People who should not receive biologics include those with active cancer, an active infection , and individuals who are systemically unwell, in general.
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Psoralen Plus Ultraviolet A
For this treatment, you’ll first be given a tablet containing compounds called psoralens, or psoralen may be applied directly to the skin. This makes your skin more sensitive to light.
Your skin is then exposed to a wavelength of light called ultraviolet A . This light penetrates your skin more deeply than ultraviolet B light.
This treatment may be used if you have severe psoriasis that has not responded to other treatment.
Side effects include nausea, headaches, burning and itchiness. You may need to wear special glasses for 24 hours after taking the tablet to prevent the development of cataracts.
Long-term use of this treatment is not encouraged, as it can increase your risk of developing skin cancer.
Biologics For Psoriasis: Side Effects And Concerns
Like other medications, biologics and biosimilars do have risks and side effects.
These may include:
- Injection-site reactions
Infections are the main risk, Dr. Hwang says.
Your doctor will rule out tuberculosis before starting you on a biologic, and then test again once a year, he says.
Theres a lot less monitoring involved with biologics compared with older drugs because of the lower risk of potential side effects.
A battery of lab tests is required with older immune-system-suppressing drugs for psoriasis, like cyclosporine and methotrexate, but not biologics, says Dr. Hwang. I see some of my patients on biologics every six months.
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Vitamin D Analogues And Combo Products
These creams, liquids, and foams are believed to stop the overgrowth of skin cells, which may help prevent future psoriasis flares. They also help clear current patches by sloughing off scaly skin and flattening plaques so they are less noticeable.
Dovonex is a synthetic form of vitamin D that comes in a cream or a liquid for scalp psoriasis. You apply it twice a day for up to eight weeks.
Vectical is a natural form of vitamin D that comes in an ointment formulation to use twice daily. While most topicals are okay to use during pregnancy, Vectical is not.
Enstilar is a foam thats a combination of a synthetic form of vitamin D and a steroid. Its approved for adults only and used once a day for up to a month.
Taclonex is a liquid vitamin D-steroid combo thats approved for use in children ages 12 and up. Use it once a day for up to a month.
Research has shown that using a vitamin D analogue with a corticosteroid may not only be more effective than using either one alone, but the combo can even reduce the side effects that can come with strong steroid use. But side effects can include:
What Are The Side Effects
There are several side effects a person may experience should they use biologics. Minor reactions may include an injection site reaction . This may appear as redness or swelling, or the site may be itchy or painful. Similarly, if a biologic is administered via transfusion, then a side effect may be an infusion reaction, which can cause redness and swelling but may also cause other symptoms like nausea, fever or chills, or a rash.
The Weakening of the Immune System
Another side effect to be wary of is that there is an increased risk of infection. Biologics weaken your immune system in order to reduce psoriasis swelling, therefore you are more open to the risk of infections. On a less severe scale, you may be more at risk of catching a cold. On a more severe scale, you may be more at risk of tuberculosis and septicaemia.
The risk of infection due to taking biologics can be referred to as common infections and opportunistic infections. Common infections relate to conditions like upper respiratory infections and pneumonia, while opportunistic infections , include TB. There is also a risk of allergic reactions when someone is taking a biologic for the first time. Before you undertake any biologic treatment, be sure to discuss these side effects with your healthcare provider who will be able to help you monitor your wellbeing before, during and after treatment.
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Can Biosimilars Be Used With Other Treatments
It is important to tell your health care provider about all treatments, medicines, vitamins or supplements that you are taking.
Like all biologics, biosimilars can be used with other treatment options including topicals and phototherapy. The biologics Enbrel, Humira and Remicade are shown to be safe and effective when taken with methotrexate. This means that their biosimilars, including Erelzi, Amjevita, and Inflectra, may be safe and effective when taken with methotrexate.
- With Inflectra being the biosimilar to Remicade, its use in combination with phototherapy may increase the risk for skin cancer.
- No drugs that interact with biologics should be combined with their respective biosimilars.
What Should People Know About Self
A person can self-inject nearly every biologic on the market in the comfort of their own home. Many companies also provide nursing support, which involves a nurse visiting the persons home to teach them to self-administer injections.
Most of the medications are administered through auto-injector pens, rather than traditional syringes, to ease the process. In some cases, people can still go to their doctors office for the injections, if they are not comfortable administering them at home.
The first step is to thoroughly clean the hands and the site of the injection. An injection should only take place in an area that is not affected by psoriasis.
Place the auto-injector flush to the skin, then press the releaser to deliver the medication. Do not lift the auto-injector from the skin until the dose has been fully administered.
Then, clean the skin again if there is a drop of blood, and apply an adhesive bandage.
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What Are The Risks Of Biosimilars
The risks and side effects of biosimilars are the same as those associated with their biologic reference product. Anyone considering taking a biosimilar should talk with their health care provider about the short- and long-term side effects and risks. It is important to weigh the risks against the benefits.
Biologics and biosimilars act on cytokines, which are specific proteins released by the immune system that can cause inflammation. Biologics suppress the function of the overactive immune system. When on a biologic or biosimilar, you may have a higher risk of infection. If you develop any signs of an infection, contact your health care provider right away.
Signs of infection include:
- Damp, sticky feeling or sweating
Who Is A Candidate For Biologics
Biologics are used for people with moderate to severe psoriasis. They may also help people who cannot use other drugs or treatments, for example those who have had an allergic reaction to another psoriasis medication. Eligibility for treatment with biologics depends on the medication used. Biologics are given by injection.
For more information, contact your dermatologist.
All material copyright MediResource Inc. 1996 2021. Terms and conditions of use. The contents herein are for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Source: www.medbroadcast.com/healthfeature/gethealthfeature/Psoriasis-Treatment-Biologics
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Who Can Take Biosimilars
All biologics, including biosmilars, are typically prescribed for people with more advanced disease, including individuals with moderate-to-severe psoriasis and active PsA. But each of the three approved biosimilars are indicated for different groups within this population.
You should not take biosimilars if:
- Your immune system is significantly compromised
- You have an active infection
Screening for tuberculosis or other infectious diseases is required before starting treatment with all biologics, including biosimilars.