Chicago — Systemic pharmaceuticals — from cyclosporine to methotrexate and everything in between — retain a relevant role in the treatment of psoriasis despite today's seemingly all encompassing focus on biologics.
"These older medications still are relevant, and still have a place in our treatment armamentarium for two reasons. First because it is not always possible to deliver a biologic to a patient who has psoriasis, and second not every patient benefits from the use of biologics," says Bruce E. Strober, M.D., Ph.D., assistant professor of dermatology, NYU School of Medicine, New York. Dr. Strober advocated for the appropriate use of conventional systemics for psoriasis at the American Academy of Dermatology's Academy '05 here.
One roadblock to the delivery of biologics is their cost.
Others who are obvious candidates for systemics are those who have contraindications to biologics, Dr. Strober points out.
Additionally, patients who have some form of immunodeficiency shouldn't receive alefacept and patients who have solid tumor or lymphoreticular cancers shouldn't receive any of the biologics, according to Dr. Strober.
Reasons for systemics
"We just don't have the data as to the safety of these newer drugs for people who have a recent history of cancer," he says. "In those instances we have to turn to drugs that we believe are safer in patients that we know have a history of malignancies. One of those drugs is acitretin. In some cases, the appropriate choice is methotrexate. So there are multiple clinical scenarios when patients shouldn't be on biologics," he stresses.
Another reason systemics remain a vital ingredient in psoriasis treatment is that not all patients get complete clearance on monotherapy with a drug such as etanercept, he says.
"In those instances we need to add a second medication, and sometimes the second medication is methotrexate or cyclosporine," Dr. Strober says. He is currently collecting data on the combination use of cyclosporine and etanercept in his own practice, and plans to submit the data for publication in the future. He points out that a lack of formal studies exploring the use of systemics in combination with biologics makes it necessary for dermatologists to rely on anecdotal evidence to make treatment decisions until further evidence is in.
"For example," he says, "There are no large formal studies looking at the combined use of cyclosporine with either etanercept or efalizumab."
One bit of direction exists in the form of the etanercept labeling, which Dr. Strober points out, allows for the use of methotrexate in combination with etanercept for people with psoriatic arthritis or rheumatoid arthritis.
In his practice, often when psoriasis patients are not clearing on etanercept or efalizumab monotherapy, Dr. Strober adds a lower dose of either cyclosporine or methotrexate.
"With cyclosporine, this could be a dose of perhaps 2 milligrams per kilogram per day or in the case of methotrexate a dose of 7.5 to 12.5 mg per week," he says. "I always add low dose methotrexate - about 10 mg per week - to infliximab to prolong its duration of efficacy."
Naturally, when these drugs are added, the patient's history and any potential contraindications to these older therapies must be taken into consideration.
"And the monitoring of those older drugs in terms of what their potential risks are to the patient has to be instituted as well," he says.