|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 1 | Page : 106-108
Dramatic response of cutaneous, nail, and joint symptoms of psoriasis to apremilast
Meghana Bathina, Amina Asfiya Iqbal, Malcolm Pinto, Manjunath M Shenoy
Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||14-Feb-2019|
Manjunath M Shenoy
Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Apremilast has been available in India for the past 6 months as a therapy for psoriasis. A 31-year-old male patient with a diagnosis of psoriasis with oligoarthritis who was not tolerating methotrexate was treated with apremilast. We noticed a dramatic response to the cutaneous and joint symptom within a month of initiation of the therapy. We also noticed improvement in the nail changes. He tolerated the drug except for an episode of diarrhea that resolved without any intervention. Apremilast is a useful addition to the therapeutic armamentarium of psoriasis and arthritis.
Keywords: Apremilast, arthritis, nail, psoriasis
|How to cite this article:|
Bathina M, Iqbal AA, Pinto M, Shenoy MM. Dramatic response of cutaneous, nail, and joint symptoms of psoriasis to apremilast. Clin Dermatol Rev 2019;3:106-8
|How to cite this URL:|
Bathina M, Iqbal AA, Pinto M, Shenoy MM. Dramatic response of cutaneous, nail, and joint symptoms of psoriasis to apremilast. Clin Dermatol Rev [serial online] 2019 [cited 2019 Jul 15];3:106-8. Available from: http://www.cdriadvlkn.org/text.asp?2019/3/1/106/252302
Psoriasis with arthritis is a crippling disease in a few patients imparting poor quality of life. There are many therapeutic modalities currently available for psoriasis and psoriatic arthropathy with varying efficacies. On the one hand, we have immunosuppressants such as methotrexate (MTX) which has long-term systemic side effects, while, on the other hand, we have biologicals which are expensive and hence not easily affordable to the patients. Apremilast is a new drug which has shown promising results in cases of psoriasis and psoriatic arthropathy. It is an orally active molecule that primarily acts as a phosphodiesterase 4 (PDE 4) inhibitor and is approved for the treatment of chronic plaque psoriasis and psoriatic arthropathy. This could emerge as an alternative treatment when aforementioned treatments are ineffective, intolerable, and expensive to the patients.
His NAPSI on admission was 80 for fingernails. For assessment of therapy, NAPSI postapremilast therapy for fingernails for the thumbnail was found to be 6 when compared to NAPSI score pretreatment which was 8.
No radiological documentation of bone and joint manifestations has been done for pre- and post-treatment objective comparison: We regret to inform that no previous records available for comparison.
The patient was irregular due to financial reasons and had taken oral methotrexate doses for the last 2 years which was subsequently increased to parenteral methotrexate 15 mg in view of the minimal response seen. He had also been using topical potent corticosteroids and emollients with minimal benefits.
His baseline liver function test (LFT) was deranged with elevated enzymes (SGOT: 77, SGPT: 120). Methotrexate was hence discontinued; other options such as cyclosporine and biologicals could not be considered due to financial constraints.
A 31-year-old male who was a known case of psoriasis vulgaris with psoriatic arthropathy of 6 years duration presented with aggravation of symptoms for 3 weeks. Cutaneous examination revealed erythematous plaques with silvery scales distributed all over the body [Figure 1]a and [Figure 2]a. He also complained of multiple joint pains of small joints of hands and ankles with restriction of flexion of multiple interphalangeal joints [Figure 3]a. His PASI on admission was 44.2. Nail changes including pitting, ridging, and subungual hyperkeratosis of almost all the finger and toenails were seen [Figure 4]a. His NAPSI on admission was 80 for fingernails. For assessment of therapy, NAPSI postapremilast therapy for fingernails for the thumbnail was found to be 6 when compared to NAPSI score pretreatment which was 8.
|Figure 1: (a) Psoriasis plaques on the lower extremities. (b) Improvement of lesions after 1 month of initiation of apremilast|
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|Figure 2: (a) Psoriasis plaques on the posterior trunk. (b) Significant improvement of lesions in 1 month after initiation of apremilast|
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|Figure 3: (a) Hands showing asymmetrical oligoarthritis involving the finger joints. (b) Improved joint swelling and mobility after 1 month of initiation of apremilast|
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|Figure 4: (a) Thumbnails showing the coarse pitting and ridging. (b) Improved appearance of the nails after 1 month of initiation of apremilast|
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He was previously treated with oral and parenteral MTX in doses (range of 7.5–15 mg per week) for the last 3 years with poor compliance and frequent relapses. The patient was irregular due to financial reasons and had taken oral MTX doses for the last 2 years which was subsequently increased to parenteral MTX 15 mg in view of the minimal response seen. He had also been using topical potent corticosteroids and emollients with minimal benefits. His baseline liver function test (LFT) was deranged with elevated enzymes (serum glutamic oxaloacetic transaminase [SGOT]: 77, serum glutamic pyruvic transaminase [SGPT]: 120). MTX was hence discontinued; other options such as cyclosporine and biologicals could not be considered due to financial constraints. Apremilast was administered in increasing doses starting from 10 mg with an increase of 10 mg every day till the maintenance dose of 30 mg twice a day was reached on the 6th day. He was then continued on the same dose and was asked to come for follow-up after a month. He was also treated with topical halobetasol and liquid paraffin twice daily. At the time of follow-up, there was significant reduction in the extent and severity of cutaneous disease with of PASI being 13.4 [Figure 1]b and [Figure 2]b and improvement in the joint symptoms [Figure 3]b. There was visible reduction in the nail changes which was also noticed by the patient [Figure 4]b. His LFT had improved and his liver enzymes were closer to the normal range (SGOT: 37, SGPT: 56) when compared to the last visit.
There were no significant adverse effects reported except for two episodes of loose motions on the 3rd day of start of therapy which spontaneously resolved.
Apremilast is a newer addition to the existing systemic therapy for psoriasis and arthritis approved by the US FDA in 2014. It acts as a competitive PDE4 inhibitor in keratinocytes. Phosphodiesterases are enzymes which hydrolyze and degrade cAMP to AMP. PDE4 inhibition results in
- Decrease in pro-inflammatory cytokine levels
- Decrease in chemokine production, for example, CXCL9, CXCL10, and CCL4
- Decreases influx of leukocytes mainly neutrophils.
It is rapidly absorbed with a Tmax of approximately 2 h and a half-life of 7–16 h. It is metabolized by cytochrome P450 pathway with minimal drug interactions noted with antiepileptic drugs such as carbamazepine, phenytoin, phenobarbital, and rifampin. It requires no therapeutic monitoring. Most common adverse effects reported have been diarrhea, nausea, headache, and depression. Although it is cheaper when compared to biologicals, it is relatively expensive when compared to conventional treatments such as MTX. Hence, it is likely to remain a second- or third-line therapy.
In our case, the patient was treated with apremilast as he could not afford the expenses of other treatments such as cyclosporine or biologicals. He was on long-term MTX therapy previously and was discontinued in view of his deranged LFT. He showed remarkable results with no significant adverse effects with apremilast.
We conclude that apremilast can be used as a monotherapy even in extensive disease and arthritis with good results and minimal adverse effects. It was cost-effective in our case and has been reported for the dramatic response to all aspects of psoriasis therapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schett G, Sloan VS, Stevens RM, Schafer P. Apremilast: A novel PDE4 inhibitor in the treatment of autoimmune and inflammatory diseases. Ther Adv Musculoskelet Dis 2010;2:271-8.
Smith RL. Pediatric psoriasis treated with apremilast. JAAD Case Rep 2016;2:89-91.
Jeon C, Nakamura M, Sekhon S, Yan D, Wu JJ, Liao W, et al.
Generalized pustular psoriasis treated with apremilast in a patient with multiple medical comorbidities. JAAD Case Rep 2017;3:495-7.
Ohtsuki M, Okubo Y, Komine M, Imafuku S, Day RM, Chen P, et al
. Apremilast, an oral phosphodiesterase 4 inhibitor, in the treatment of Japanese patients with moderate to severe plaque psoriasis: Efficacy, safety and tolerability results from a phase 2b randomized controlled trial. J Dermatol 2017;44:873-84.
Reed M, Crosbie D. Apremilast in the treatment of psoriatic arthritis: A perspective review. Ther Adv Musculoskelet Dis 2017;9:45-53.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]