NEWPORT BEACH, CALIF. – Monoclonal tumor necrosis factor inhibitors such as adalimumab are the go-to treatments for management of psoriasis in obese patients.
Some anti–tumor necrosis factor inhibitors (anti-TNFs) are good treatments for patients with a healthy weight whose psoriasis requires systemic treatment, according to Dr. Jennifer Cather, medical director of the Modern Dermatology-Aesthetics Center in Dallas.
"It would be great to be able to do a cream and light therapy, but for a lot of people that’s just not going to work. The TNF antagonists are my treatment of choice" in those cases, said Dr. Cather, also codirector of the Cutaneous Lymphoma Clinic at Baylor University Medical Center in Dallas.
But obese psoriasis patients "can have success with adalimumab even after failing or partially responding to etanercept," she said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.
Etanercept is her go-to, however, for people who aren’t overweight and "for my peripregnancy people. It seems like they can come on and off it multiple times [as needed and still] do okay." TNF inhibitors are pregnancy category B agents, but "people are reticent to use them" during pregnancy, Dr. Cather noted.
Infliximab is an option as well, but "I have all my infliximab administered by infectious disease [specialists so that patients can be tested for infection with hepatitis B or hepatitis C virus and tuberculosis], and rheumatologists assume care," she said.
Concomitant use of methotrexate can boost the efficacy of TNF inhibitors in the management of psoriasis. In addition, to find the drug that best suits the patient, various anti-TNF agents can be given a trial and stopped if there is no response, and another drug can be initiated. Dr. Cather said that she draws the line at two anti-TNF agents. If a patient has not responded to two of these agents, "usually I’m not going to do a third," she said.
"You want to make sure people are healthy when you put them on [these biologics]. I want to make sure they don’t have [infections or] cancer," both possible risks with treatment. "You have to ask women about cervical dysplasia," because immunosuppression may add fuel to a simmering neoplastic fire, she said.
New-onset, treatment-induced psoriasis is also a possibility. "Nobody really knows what to do with this. Everybody tries to treat through, but if they are getting localized palmoplantar pustular psoriasis, usually you are not going to be able to." Rotating between agents might help, as might adding methotrexate. The retinoid "acitretin works well for pustular psoriasis," Dr. Cather said.
"Remember," she added, "you’ve got to stop the picking in psoriasis." Shiny lesions are a hint that patients have picked off the scales. When they do that, "their plaques actually get thicker. A little bit of [the pain drug gabapentin], 100-300 mg at night, really helps people with this," she said.
Primary care providers may not know that psoriasis is a risk factor for cardiovascular disease and may not routinely screen psoriasis patients for other risk factors. So "when I have a new psoriasis patient, I will write their primary care doctor" and suggest they do so, she said.
Dr. Cather is a consultant, speaker, or researcher for Abbott, Amgen, Calgene, Centocor, Leo Pharma, Novartis, and Pfizer. SDEF and this news organization are owned by Frontline Medical Communications.