Psoriasis - Other Medications

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To reduce complications of cyclosporine, the dosage is decreased after improvement occurs. Maintenance therapy is usually limited to a year, although some experts believe that a microemulsion form of Neoral (Neoral-Neo) may be safe to use for up to 2 years. Patients should be monitored regularly for high blood pressure and signs of kidney or liver problems and skin cancers.

Patients Who Should not Use Cyclosporine. Because the drug suppresses the immune system, people with active infections or cancer should avoid it. Patients with uncontrolled high blood pressure and impaired kidney function should also not use this medication. Cyclosporine therapy for children with psoriasis has not been well studied.

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Drug and Food Interactions. Cyclosporine interacts with numerous drugs -- both prescription and over-the-counter preparations -- as well as grapefruit and grapefruit juice.

Newer forms of cyclosporine that have fewer side effects are being investigated.

Biological Response Modifiers

Biological response modifiers, sometimes called "biologics," belong to a new class of drugs that are considered the most exciting development in psoriasis treatment. Biologics are genetically engineered drugs that interfere with specific components of the autoimmune response. Because of their precise targets, these drugs do not damage the entire immune system like general immunosuppressants.

Biologics are traditionally second- or third-line treatments, and may be used alone or in combination with first-line systemic drugs. Depending on the severity of psoriasis, some of these drugs may be used earlier in the course of treatment. Studies of these medications have primarily been done on patients who are over 18 years old.

There are different types of biologics used to treat psoriasis:

• T cell blockers block immune cells linked to inflammation.
• Tumor necrosis factor (TNF) blockers target the chemical messenger TNF-alpha, which is released during the inflammatory response.

Types of T-cell blockers:

• Alefacept (Amevive). This drug is approved for the treatment of moderate-to-severe plaque psoriasis. It is very effective for psoriasis of the scalp. However, it doesn't work for all patients. Alefacept is given in a doctor's office or clinic. Patients receive weekly injections for 12 weeks. They need blood tests every 2 weeks to make sure T cell levels do not drop too low. Side effects are generally mild and include sore throat, dizziness, and cough. There have been a few reports of serious infections and cancer.

Types of TNF blockers:

• Etanercept (Enbrel) is approved for the treatment of moderate-to-severe plaque psoriasis. The drug is given either alone or in combination with methotrexate. Side effects include infections and lymphoma (a type of cancer). Patients inject themselves under the skin once or twice a week for 12 weeks. Continuing etanercept after 12 weeks may lower the severity of disease without increasing infections or side effects. The drug may be effective in psoriasis patients who have not responded to biologic drugs or other therapies, and it is also effective in patients who have not already received biologic treatments. Although etanercept has not been studied in children who have psoriasis, it has been shown to be safe and effective for treating children with rheumatoid arthritis.
• Adalimumab (Humira) has been approved for moderate-to-severe chronic plaque psoriasis. It is given by injection weekly at first, and then bi-weekly. This drug is also approved for psoriatic arthritis.

Side effects and risks of TNF blockers:

• All of the TNF inhibitors carry the potential for an increased risk of infection. Upper respiratory infections are the most common infections that occur.
• Uncommon fungal infections have also been reported as an increased risk in people using anti-TNF medications. In 2009, the FDA has issued a warning to healthcare professionals, stressing the need to test for these infections in people using anti-TNF medications who display symptoms of body-wide (systemic) illness. Because these infections are uncommon, previous delays in diagnosis have resulted in death in some patients.
• Patients receiving these drugs are at risk of reactivating old tuberculosis (TB) infections. Patients are also at higher risk for developing TB. The FDA recommends TB screening with a purified protein derivation (PPD) scan test.
• Whether TNF inhibitors increase the risk for lymphoma and skin cancers is a debated issue.

Other Second- and Third-Line Treatments

Sulfasalazine. Sulfasalazine (Azulfidine) is sometimes used for psoriasis. Many people, however, stop taking the drug because of common side effects that include headaches, gastrointestinal complaints, and rash. Benefits, if any, should be apparent in 4 - 6 weeks.

Immunosuppressants. Some immunosuppressants being studied for psoriasis include tacrolimus (Prograf), pimecrolium, and sirolimus. Studies have been limited, however. Side effects of these medications are similar to those of cyclosporine. Pimecrolimus may specifically target the skin and have fewer side effects. (Some immunosuppressants are also being studied as topical treatments.)

Review Date: 10/21/2010
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).