Take 5: Recent Developments in Systemic Therapy for Psoriasis

1. Cyclosporine Affirmed.
Despite a paucity of evidence-based studies, cyclosporine remains a safe and effective drug for the treatment of psoriasis, according to the 2008 National Psoriasis Foundation Consensus Conference (J Am Acad Dermatol 2009 Nov 23, e-pub). Specifically, researchers noted that cyclosporine is “particularly useful in managing psoriatic crises, treating psoriasis unresponsive to other modalities, bridging to other therapies, and treating psoriasis within a rotational scheme of other medications.” The panel emphasized appropriate monitoring to minimize risks.

2. Methotrexate LFTs Addresed.
During his presentation at the AAD Annual Meeting in Miami last month, Mark Lebwohl, MD referenced a report from the National Psoriasis Foundation suggesting new guidelines for use of methotrexate. The report notes that PPD tests should be performed during baseline monitoring, in addition to other tests. He also observed that monitoring for hepatoxicity is as important for lower-risk patients. While baseline liver biopsies are not essential, he notes that it is important to monitor liver function tests monthly for the first six months of treatment and then one to two months thereafter.

3. Interactions Identified.
Methotrexate and cyclosporine may adversely interact with medications commonly used in patients with psoriasis, a new report reminds (Dermatology. 220: 128-137). The study evaluated rates of reported drug-related toxicity among patients with psoriasis who were exposed or not exposed to potential drug interactions. Results showed that exposed patients had significantly greater risks of developing renal, gastrointestinal, and pulmonary events, and significantly greater health care resource utilization. Researchers concluded that methotrexate or cyclosporine polypharmacy is prevalent among psoriasis patients and associated with significant risks.

4. Low-dose Acitretin Taking Hold.
Lower dose acitretin (25mg) has been found effective for psoriasis and is associated with fewer adverse events, such as dry skin, alopecia, and rhinitis than high dose (50mg) acitretin (Arch Dermatol. 142(8): 1000-4). Dr. Lebwohl also noted in his presentation that a new meta-analysis shows low-dose acitretin may be becoming standard: more than 81 percent of written prescriptions for acitretin were for 25mg or less.

5. Cost-efficiency Highlighted.
In the wake of rising biologic costs, traditional systemic therapies may be more cost-efficient (Arch Dermatol. 146(1): 46-54). Researchers analyzed annual trends in the cost of both generic and brand-name psoriasis drugs from 2000 through 2008. Current total annual costs for systemic psoriasis therapies ranged from $1,197 (methotrexate) to $27,577 (alefacept, two 12-week courses). The average wholesale price of brand-name psoriasis therapies from 2000 through 2008 increased 66 percent on average. Researchers concluded that despite higher monitoring costs associated with traditional systemic therapies, annual costs of biologics exceed those of other therapies. Systemic psoriasis therapy costs are increasing at a much higher rate compared with general inflation.