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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
asthma
allergic rhinitis
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:
Should we apply before or after sun exposure?
Route
Most common ADRs
Indication
AFTER sun exposure
topical
Skin Irritation ADRs
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:
Pimecromilus
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