Psoriasis- Heeter

1st line pharm therapy for AD

Topical Hydrocortisone (Topical Corticosteroids)

2nd line pharm therapy for AD

Topical Calcineurin Inhibitors

Name 2 Topical Calcineurin Inhibitors

• Tacrolimus

• Pimecrolimus

Components of Atopic Triad

1. asthma

2. allergic rhinitis

3. atopic dermatitis

( Think 3 A’s)

Topical PDE-4 Inhibitor

• generic name

• indication

• Approved for what ages

• Crisaborale

• mild-moderate AD

• anyone over 3 months old

For patients with AD, that are not responding to topical therapy, what systemic agents can be used?

• Dupilumab

• JAK Inhibitors

  • Abrocitinib

  • Upadacitinib

JAK Inhibitors are used for what kind of AD?

Refractory ONLY

Dupilumab is approved for what ages?

anyone older than 6 months old

What is the clinical presentation of Atopic dermatitis?

• red, dry, thick patches

• itchy

Does AD or psoriasis have a cure?

NO

Non-pharm treatment of AD

• hydrate

• reduce triggers

• tepid shows, non-scented soaps, pat dry skin

• stop scratching

List some environmental factors that trigger psoriasis:

• infection

• DRUGS

• STRESS

• TOBACCO/ALCOHOL USE

• obesity

Withdrawal of systemic corticosteroids and NSAIDs can trigger ___________.

a. AD

b. psychological stress

c. psoriatic arthritis

d. psoriasis

d. PSORIASIS

(know these two actions can trigger)

Psoriasis is characterized by ________ ______________ turnover.

a. slow, epidermal

b. fast, epidermal

c. slow, dermal

d. fast, dermal

b.

Psoriasis is characterized by fast epidermal turnover.

What comorbidities (additional illnesses) are commonly seen with psoriasis?

• psoriatic arthritis

• metabolic syndrome

• other immune disorders

What is the most common classification of psoriasis?

plaque

Signs of plaque psoriasis:

• sharply demarcated

• bright red plaques w/ silvery scales

• itchy

MILD psoriasis:

• PASI

• BSA involvement

• PASI < 8

• BSA: ≤ 5 %

(KNOW THIS)

MODERATE psoriasis:

• PASI

• BSA involvement

• PASI ≥ 8

• BSA: >5% - <10% (aka greater than 5 % less than 10%)

(KNOW THIS)

SEVERE psoriasis:

• PASI

• BSA involvement

• PASI ≥ 10

• BSA: ≥10 %

(KNOW THIS)

A patient with psoriasis on 6% of his body would be considered to have:

a. mild

b. moderate

c. severe

Moderate

List some non-pharm treatments for psoriasis:

• reminder: will not control psoriasis alone

• reduce stress

• lose weight

• no tobacco/alcohol

• use sunscreen

ROA preferred for mild- moderate psoriasis:

a. systemic

b. topical

c. enteral

d. transdermal

b - TOPICAL

ROA preferred for moderate-severe psoriasis:

a. systemic

b. topical

c. enteral

d. transdermal

a - SYSTEMIC

1st line pharm therapy for psoriasis:

topical corticosteroids

List the Potent Corticosteroids:

• B___________ _____________

• C___________ _____________

• D___________ _____________

• F____________ _____________

• betamethasone dipropionate

• clobetasol propionate

• desoximetasone

• fluocinonide

(THINK: for potEnt corticosteroids skip “E”. It goes B, C, D, skip E, F and that’s the first letter of the ones we have to remember)

List Mid-Strength Corticosteroids:

• B____________ _____________

• H____________ _____________

• F_____________

• Betamethasone valerate

• hydrocortisone valerate

• fluocinolone

List Mild Corticosteroids:

• D____________

• F_____________

• H_____________

• desonide

• fluocinolone

• hydrocortisone

Which of the following corticosteroids has the least potency?

a. desonide

b. betamethasone valerate

c. desoximetasone

d. hydrocortisone valerate

a - desonide

Answer the following about Vit D3 Analogs:

1. Should we apply before or after sun exposure?

2. Route

3. Most common ADRs

4. Indication

1. AFTER sun exposure

2. topical

3. Skin Irritation ADRs

4. 1st-line monotherapy

Generic name of the Vit D3 Analogue we need to know:

Calcipotriene

Generic name of Retinoid used for topical psoriasis treatment:

Tazarotene

Tazarotene is contraindicated in…

pregnancy

ADR of Tazarotene

• skin irritation

Generic Names for Calcineurin Inhibitors:

1. Pimecromilus

2. Tacrolimus

Pimecromilus and Tacrolimus (Calcineurin Inhibitors) off label use and approved use:

Off-label: psoriasis

Approved: AD

Calcineurin Inhibitors Route:

topical

Answer the following about Anthralin:

• Anthralin is only used in ___________ ___________ ________

• ADRs:

• Route

• used in really thick plaques

• skin irritation ADRs

• topical

Do we use coal tar for treatment of psoriasis usually?

no

Salicylic acid can be useful to help skin penetration of ______________

corticosteroids

Salicylic acid Route:

topical

Answer the following about JAK Inhibitors and psoriasis:

• approved use

• off-label use

• route

• ADRs

• approved for AD

• off-label for psoriasis

  • RARELY USED

• topical

• skin irritation/ maligancy

Ruxolitinib belongs to what class?

JAK Inhibitor

With topical treatments of psoriasis think this ADR:

skin irritation

Acitretin

• Route

• class

• Effective?

• ADRs

• oral

• retinoid

• less effective than MTX or cyclosporine

• TERATOGENIC

  • birth control for 3 years

Cyclosporine

• Efficacy

• Dosing

• Route

• similar efficacy to MTX

• must taper doses over weeks

• oral
  

Methotrexate

• Efficacy

• Contraindications

• ADRs

• route

• What supplement must add if taking this medication?

• OUR DRUG OF CHOICE FOR SEVERE PSORIASIS

• Unless HEPATIC issues, use over cyclosporine

• ADRs: Liver toxicity, PREGNANCY

  • need birth control

• oral

• add FOLIC ACID supplement

What are our 4 oral JAK Inhibitors?

• Abrocitinib

• Deucravacitinib

• Tofacitinib

• Upadacitinib

JAK Inhibitors for severe psoriasis:

• Route

• ADRs

(Know the 4 generic names from this class)

• oral

• ADRs:

  • infection

  • mortality

  • malignancy

  • MAJOR ADVERSE CV EVENTS

  • THROMBOSIS
    

Dosing Frequency for JAK Inhibitors:

• Abrocitinib

• Deucravacitinib

• Tofacitinib

• Upadacitinib

All once daily except for Tofacitinib

• Abrocitinib- once daily

• Deucravacitinib- once daily

• Tofacitinib- IR tab BID or ER tab daily

• Upadacitinib- once daily

PDE-4 Inhibitor for severe psoriasis:

• Generic Name

• Route

• Warnings/ADRs

• Apremilast

• oral

• Depression, weight loss, drug interactions, Diarrhea, vomiting

Biologic Response Modifiers:

• ADRs

• Warnings

(This wasn’t necessarily in the slides, I just think it’s helpful when you think of this class, think these ADRs and warnings bc it’s a common theme)

• Common warnings: infection, TB, malignancy

• most ADRs: HA, hypersensitivity, Ab formation

Biologic Response Markers are typically administered…

• IV or SUB-Q

TNF-a Inhibitors

• Black box warnings

• ADRs

• BLACK BOX WARNINGS:

  • Risk of infection

  • Heart failure

  • Malignancy

  • Tuberculosis

• ADRs: Infusion Rxns

To reduce Infusion reactions you could

Pretreat with

• antihistamines

• APAP

• corticosteroids

IL12 and 23 Inhibitors

• Black Box Warning

• ADRs

• BLACK BOX WARNINGS:

  • Risk of infection

  • Malignancy

  • Tuberculosis

• ADRs: NEUROTOXICITY, Ab formation, HA

IL 17 Inhibitors

• Unique program that is offered

• ADRs

• Siliq REMS PROGRAM- for suicidial ideations

• ADRS in Brodalimumab and Bimekizumab:

  • infection

  • TB

  • SUICIDAL IDEATION/ DEPRESSION

T-cell Inhibitors

• Warnings

• ADRs

• Infection, Malignancy

• Common ADRs: HA, N, Ab formation, infection, URTI

IL 23 Inhibitors ADRs

• infection

• TB

Know all the biologic Response Modifiers and what class they belong to, indication, and route