1. Psoriasis What’s New Dr. Vincent P Beltrani
Clinical Instructor of Dermatology
Columbia University College of Physicians and Surgeons

2. Old concepts Psoriasis is just a skin disease
--minimal impact on quality of life
--no association with other comorbidities
Effective drugs are often discovered accidentally

3. New concepts
Psoriasis is an inflammatory disease of the skin and joints that is often a reflection of more pervasive systemic inflammation.
Moderate to severe psoriasis is associated with numerous common comorbidities.
Modern treatments are specifically designed to target proinflammatory cytokines implicated in the pathogenesis of psoriasis

4. Psoriasis Comorbities
Obesity
Cardiovascular disease including myocardial infarction, stroke, hypertension
Diabetes
Hyperlipidemia
Psoriatic arthritis
Crohn’s disease
Lymphoma
Psychiatric disease
Increase risk mortality

5. Treatment of moderate to severe psoriasis reduces risks of comorbities
In one meta-analysis, standardized mortality rates in treated patients was less than 1 (less than expected in the general population)

6. Old Systemic Drugs Methotrexate Cyclosporine Acetretin
Mycophenolic acid and other immunosuppressive agents
(phototherapy)

7. Methotrexate First used 1947 for childhood leukemia
1951 noted to have positive effects on psoriasis and RA
1971 approved for psoriasis
1988 approved for RA
Adverse effects and toxicity-patient selection
Drug interactions
Contraindications
PASI 75 approx 35%

8. Cyclosporine 1983 approved for organ transplantation
1997 approved for psoriasis
Adverse effects and toxicity
Drug interactions
Contraindications
PASI 75 approx 50-70%

9. Etretinate/Acetretin
1986/1997 approved for psoriasis
Adverse effects and toxicity
Drug interactions
Contraindications
PASI 75 approx 34-52%

10. New Systemic drugs Etanercept (Enbrel) Infliximab (Remicaide)
Adalimumab (Humira)
Ustekinumab (Stelara)
Secukinumab (Cosentyx)
Ixekizumab (Taltz)
Apremilast (Otezla)

11. Psoriasis cytokines

12. Psoriasis cytokines

13. etanercept/Enbrel 1998 approved for RA 2004 approved for psoriasis
Nov 2016 approved for childhood psoriasis to age 4
Soluble TNF receptor
PASI 75 approx 44%

14. infliximab/Remiciade
1998 approved for Crohn’s disease
1999 approved for RA
2006 approved for psoriasis
IV chimeric monoclonal antibody to TNF
PASI 75 approx 80%

15. adalimumab/Humira 2002 approved for RA
2008 approved for psoriasis (at that time, the 5th indication for adalimumab)
Now approved for 10 indications
Human monoclonal antibody to TNF
PASI 75 approx 71%

16. Monitoring of TNF inhibitors
Baseline TB test and HBV screening
Periodic CBC/CMP ?
Pregnancy category B

17. ustekinumab/Stelara 2009 approved for psoriasis 2013 approved for PsA
2016 approved for Crohn’s disease
Human monoclonal antibody to IL-12 and IL-23
PASI 70 approx 75%
Monitoring-baseline TB test
Pregnancy category B

18. secukinumab/Cosentyx
2015 approved for psoriasis
2016 approved for PsA and AS
Human monoclonal IgG1 antibody to IL-17
PASI 75 approx 82% at week 12
Monitoring-baseline TB test
Pregnancy category B

19. ixekizumab/Taltz March 2016 approved for psoriasis
Humanized monoclonal IgG4 antibody to IL-17
PASI 75 approx 89%
Monitoring-baseline TB test
Pregnancy category B

20. apremilast/Otezla 2014 approved for Psoriasis and PsA
Orally administered “small molecule” inhibitor of PDE4. PDE4 breaks down cAMP. Increased cAMP down regulates TNF, IL-17 and 23.
PASI 75 approx 33%. Higher over time?
Monitoring-none
Pregnancy category C