'Forgotten' systemic drugs for psoriasis

With the recent discoveries of immunologic pathways leading to psoriasis, clinicians are likely to discount older general immunosuppressive agents in favor of newer larger molecules like biologics that provide better targeted therapy. But this is not always necessary, according to Mark D. Kaufmann, MD, an associate clinical professor of dermatology at Icahn School of Medicine at Mount Sinai in New York City.

“Practitioners should revisit these older drugs because the outcomes and safety issues using them have improved through the years,” Dr. Kaufmann tells Dermatology Times in a follow-up interview about his presentation on systemic therapeutics at the Summer American Academy of Dermatology meeting.

For example, methotrexate is typically administered in oral formulation. “However, there are many patients who cannot tolerate taking the drug orally,” Dr. Kaufmann says. “Fortunately, a subcutaneous autoinjector of methotrexate has been developed over the past few years.”

According to the rheumatologic literature, this new formulation of methotrexate has more predictable bioavailability in the bloodstream; “therefore, this delivery option can provide superior efficacy in the disease treatment, and better tolerability because it bypasses the GI tract,” Dr. Kaufman reports.

Offering a medication like methotrexate, without most of the traditional side effects that prevent patients from taking it, “could lead to a better uptake of the medicine, increased usage, enhanced results, and perhaps avoiding the need to advance to more expensive biologics,” Dr. Kaufmann says.

Dr. Kaufmann notes that some dermatologists in the United Kingdom, are suggesting subcutaneous methotrexate as potentially more effective in treating psoriasis than the oral form, and that it might be more efficacious to start with the subcutaneous form. “With more positive results, there will be less reliance on biologics, thereby saving their national healthcare system a tremendous amount of money,” he says.

Cyclosporin is a second older drug for psoriasis that Dr. Kaufmann advocates. “Cyclosporin is still an excellent drug to use, as long as we keep in mind that the goal is for short-term usage and not as a long-term solution because that is when more side effects emerge,” he says.

Still, for both methotrexate and cyclosporine, patient selection and proper monitoring are key.