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Newer Therapeutics in Psoriatic Arthritis

June 10 2015 7:39 AM ET via RheumReports RheumReports

Imagine you’re in clinic and seeing a 65-year-old patient with long-standing psoriatic arthritis. He has hypertension, scalp psoriasis and a positive Tb skin test. He has been treated with sulfasalazine, methotrexate, prednisone, and NSAIDs. He was recently found to have prostate cancer treated with radiation and hormone therapy.

He was treated with an anti-TNF for 3 years. The anti-TNF was stopped due to a recurrence of his prostate cancer. Unfortunately his arthritis flared. What do you do now?

This is one example of the issues that can arise when treating patients with psoriatic arthritis. Following DMARD failure the options have been largely limited to biologic therapy. Biologic therapy therapy is very effective for a large number of patients but can be limited by contraindications and side effects including recurrent infection, tuberculosis, and malignancy.

A new therapeutic agent on the marketplace in some areas (anticipated to become available in Canada) for psoriatic arthritis is apremilast (Otezla). With the above patient in mind, apremilast has not been shown to have an association with malignancy, tuberculosis, or serious infection. In fact, there are no blackbox warnings, no risk of serious infection, no requirement to screen for Tb, no required laboratory monitoring, and no vaccination recommendations. This makes for a very promising therapeutic agent.

I had a chance to sit and chat with some of the physicians involved with the clinical trials using apremilast. All of these physicians had positive comments about the efficacy of this therapy. Furthermore, these physicians had the perception that this medication seemed more effective than they had anticipated based on the clinical data.

For rheumatologists, one of the challenges in treating patients with psoriatic arthritis is dacylitis and enthesitis. Does apremilast help to treat either of these conditions? The short answer is yes. In clinical trials, dactylitis completely resolved in 75% of patients by week 104 whereas enthesitis resolved in 50% of patients in the same time period.

From our discussions, it was clear that the two main side effects of nausea and diarrhea were the largest contributors toward discontinuation of therapy. However, in some patients, these side effects would be expected to improve with persistence of therapy.

Other side effects of apremilast include weight loss, headaches, depression, and rarely suicidal ideation (See our Apremilast Information Sheet). Most of these side effects were mild to moderate, occurred in the first 2 weeks of therapy and improved over the following 2 weeks. The dose of apremilast should be reduced to 30 mg QD in cases of severe renal impairment (CrCl < 30).

Given the potential side effect of weight loss, this therapy may be an attractive option for some patients. Weight loss was reported in about 15-20% of patients but it's important to realize that some patients (5-8%) actually gained weight.

Apremilast is a therapy with a favourable benefit-to-risk ratio that fills  a much needed therapeutic void for patients with psoriatic arthritis. 


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About the Author

Dr. Andy Thompson
Dr. Andy Thompson

Dr. Andy Thompson is an Associate Professor at Western University and founder of Rheuminfo.com, Rheumtalks.com, and RheumReports.com.

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