This is ReachMD, and you’re listening to Psoriasis: What’s Beneath the Surface, sponsored by Lilly.
On this episode we’ll hear from Dr. Shari Lipner, Associate Professor of Clinical Dermatology at Weill Cornell Medicine in New York City. Dr. Lipner shares the recently updated guidelines on psoriasis treatment from the AAD and NPF. Here’s Dr. Lipner.
Dr. Shari Lipner:
So, this joint AAD-NPF guideline was an update and expansion on the previously published 2008 AAD psoriasis guideline. So, we really did need an update on this because it’s been more than ten years, and there are a lot of new biologics on the market, a lot of new options for patients, and a lot of new data about efficacy and safety of these medications. This was a two-part guideline, and in the first part, it emphasizes treatment recommendations and the role of the dermatologist in monitoring and educating patients regarding the benefits and risks of use of biologics, and some of the highlights were that the biologics can be combined with topicals, light therapy, methotrexate, and acitretin in patients who have only a partial response, and this, in general, is safe to do. Another highlight of these guidelines explain that because there is a risk of antibodies to infliximab, there are a significant number of patients who will lose clinical response, so the addition of methotrexate to infliximab should be considered for all patients.
Another highlight from these guidelines was that a definitive response, and that means either positive or negative, to treatment with all classes of the biologics is best ascertained after 12-16 weeks of continuous therapy. The one exception is for infliximab, where the best time to assess is between eight and ten weeks.
A new update is also that on the basis of an expert opinion, all biologics can be continued through low-risk surgical procedures in patients with psoriasis and psoriatic arthritis, and these low-risk surgical procedures are defined as surgical procedures without a break in sterile technique, during which the respiratory, GI, and GU tracts are not entered. It’s a different story for patients with moderate to high-risk surgical procedures that are planned, and this is really more of a case-by-case approach in collaboration with the surgeon. So, it’s well accepted that inactivated or dead vaccines may be given during treatment with all biologics. However, for administration of live vaccines, it’s best to consult with an infectious disease specialist.
In terms of discontinuing the biologic, there is not a complete consensus on that. However, most advise discontinuation of the biologic four weeks before and until one to two weeks after vaccination, and that four-week period may also depend on the half-life of the biologic. In part two of the guidelines, the American Academy of Dermatology and the National Psoriasis Foundation has guidelines for the care and management and treatment of psoriasis with awareness and attention to comorbidities. So, this recognizes the fact that patients with psoriasis have extracutaneous manifestations, and these include comorbid conditions, mental health, psychosocial wellness, and quality of life, and dermatologists play a very important role in screening for psoriatic arthritis and informing patients about this important association.
Dermatologists also should be warning patients about the association of psoriasis with both the cardiovascular disease and the metabolic syndrome, and they should make sure that their patients are actively engaged with their primary care doctor or cardiologist for appropriate screening. We know that smoking and excessive alcohol ingestion are associated with psoriasis and its severity, and increased usage of either substance will further affect disease severity, and we know that cessation of both alcohol and smoking will improve psoriasis symptoms over time.
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