PracticalDermatology

Stack Injections

According to Mark Lebwohl, MD, Professor of Dermatology and Internal Medicine at Mount Sinai School of Medicine in New York, patients receiving adalimumab (Humira, Abbott) achieve maximum therapeutic benefit when receiving two injections in the first week of therapy initiation. Since most insurance companies will only allow for one injection in the first week, Dr. Lebwohl provides his patients the injecting materials and instructs them to wait one week before staring the drug. When patients receive their second allotment of medication in week two, they can then take both injections at once.

Know Heart Health Facts
Although the package inserts for anti-TNF agents indicate that patients may be at greater risk of myocardial infarction and heart disease, Dr. Lebwohl observed that when used at the appropriate doses (usually no greater than 5mg/kg, depending on the agent), TNF blockers may actually reduce the risk of congestive heart failure. When prescribing anti-TNF agents, Dr. Lebwohl recommends calling the patient's cardiologist to assess any outlying risks that may affect treatment. Most often, cardiologists will have little hesitation when recommending patients for anti-TNF therapy.

Maximize and Expedite Treatment
Although current psoriasis classification guidelines indicate that systemic treatments should only be used when topical therapy is unsuccessful, David Pariser, MD, Professor of Dermatology at Eastern Virginia Medical School in Norfolk, VA suggests that certain cases warrant skipping topical therapy altogether. To determine optimal treatment regimens, Dr. Pariser notes that the patient and physician might benefit from discussing early on what the patient is willing to do to treat psoriasis.

Revisit Vitamin D
One of the newer and more successful topical therapies for the treatment of psoriasis is calcitriol ointment (Vectical, Galderma), according to Roger I. Ceilley, MD, a dermatologist in private practice in Des Moines, IA. Dr. Ceilley notes that the ointment, recently approved by the FDA, is less irritating than calcipotriene while offering similar high efficacy rates.

Beware of PML Risks
Dr. Pariser also addressed heightened concerns over the risk of progressive multifocal leukoencephalopathy with some biologic therapies (See "Recent Developments," p. 9). Dr. Pariser indicated that in the last year, there have been three reported cases of PML in patients taking efalizumab (Raptiva, Genentech). When starting patients on T-cell inhibitors, he recommends fully informing them of risks and always leaving open the option to switch therapies. In light of the concerns, he says, physicians must weigh with patients what it's worth to relieve psoriasis symptoms. n