Psoriasis Treatment Transition Pathway

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1 Psoriasis Treatment Transition Pathway A Treatment Support Tool Adapted from Circle Nottingham NHS Treatment Centre Psoriasis Pathway (under consultation) with support from Abbvie Ltd

2 Treatment Pathways Nurse led clinics for psoriasis should be considered for delivery of services such as follow up of specialist caseload, re access for patients with recurrent disease, and monitoring of systemic therapies. 2

3 Consider treatment options 2 Consider monotherapy that addresses both skin and joint disease in preference to multiple therapies. Initial treatment options usually include topical therapy, phototherapy or systemic therapies: If these treatment options are contraindicated in patients with severe psoriasis, offer biologic therapy. Topical therapy and review 2 For well-defined plaques a vitamin D or vitamin D analogue is recommended for long-term treatment. Not suitable for widespread disease (see BNF for recommended weekly/daily maximum doses). If a vitamin D or vitamin D analogue is ineffective or not tolerated then consider coal tar, tazarotene gel, or short contact dithranol. Short term intermittent use of a potent topical corticosteroid or a combined potent corticosteroid plus calcipotriol ointment can be used to gain rapid improvement in plaque psoriasis if extent is limited. Potent to very potent topical corticosteroids are not recommended for regular use over prolonged periods. Patients with guttate psoriasis should be considered for early referral for UVB if unresponsive to topical therapy or widespread disease. Patients who do not respond to topical therapy should be offered narrow band UVB (NBUVB) if available, or systemic therapy. Phototherapy and review 2,6 Ultraviolet B (UVB): narrow band UVB (NBUVB) is the treatment of choice: three times a week for patients unable to attend hospital, offer home NBUVB under controlled supervision broad band UVB (BBUVB) is not recommended more likely to cause burning than NBUVB NBUVB is demonstrated to be at least as effective as psoralen and ultraviolet A (PUVA) not advisable for use in patients with a history of: skin malignancy xeroderma pigmentosum systemic lupus erythematosus (SLE) considered to be safe for use in children and pregnant patients, can be used in combination with acitretin. Psoralen and ultraviolet A (PUVA): consider for patients who do not respond to NBUVB or if short remission. various psoralen preparations can be used for photosensitising effects, either oral or topically applied there is an increased risk of skin cancer with long term use of tablet-puva therapy theoretical risk of cataract formation - use of sunglasses is advised for 24 hours after taking oral psoralen

4 Systemic therapies and review 2,6 Following a discussion of benefits and risks, patients with severe or refractory psoriasis should be considered for systemic therapy with ciclosporin, methotrexate or acitretin. Pregnant women should not be treated with systemic agents. 2 Methotrexate: Recommended for longer term use and where there is concomitant psoriatic arthritis. Use incremental dosing starting at 5mg and titrate to a maximum of 25 mg (expert opinion dosage). Acitretin: Not recommended for women of childbearing potential. Suggested dose 10-25mg daily. Can be combined with phototherapy to increase efficacy (expert opinion). Ciclosporin: Recommended for short term intermittent use or where rapid intervention is required. 2-3mg/kg a day, maximum 5mg/kg a day. Fumaric acid esters or hydroxycarbamide can be considered for patients who are not suitable for other systemic therapies or have failed other therapies, but they are not licensed in the UK. 1,2,4,7,8,9, 10 Consider/Review Biologic therapies TNF antagonists are recommended first-line for patients meeting criteria for treatment with biologic therapies. anti-tnfs (Consider indications and co-morbidities such as joint disease) adalimumab (use 1st line in accordance with BAD guidelines for rapid and stable control) etanercept infliximab anti-il12/232 ustekinumab (Use 2nd line in accordance to NICE) The use of biologic treatments should conform to BAD guidelines. Consider addition of a systemic therapy if unresponsive. Initial treatment period Allow weeks of treatment before reviewing to assess whether the patient has responded to treatment: 10 weeks for infliximab (TA134), 12 weeks for etanercept (TA103) and 16 weeks for adalimumab (TA146). 1 Adalimumab recommended initial loading dose of 80 mg subcutaneous injection followed by 40 mg given subcutaneously every other week starting 1 week after initial loading dose for adults with severe disease as defined by a total PASI of 10 and a DLQI of >10. 7 Etanercept - recommended dose not to exceed 25 mg twice weekly for adults with severe disease as defined by a total PASI of >10 and a DLQI of >10. 8 Infliximab recommended dose of 5 mg/kg intravenous infusion over a 2-hour period followed by additional 5 mg/kg infusion doses at 2 and 6 weeks after the first infusion and then every 8 weeks thereafter, for patients with very severe disease defined by a total PASI of 20 and a DLQI >18. 9

5 Psoriasis referral to dermatology secondary care 2,6 Psoriasis is an immune condition which causes symptoms on the skin and sometimes the joints. The current thinking is that psoriasis affects between 2% 3% of the UK population, up to 1.8M people although this is an estimate. Patients may be referred to dermatology for a variety of reasons: generalised pustular or erythrodermic psoriasis emergency referral if Dermatology Life Quality Index (DLQI) was more than 5 if patients with guttate psoriasis have not responded to topical therapy if there was a lack of response to topical therapies (allow reasonable trial of 2 3 months) adverse reactions to treatment extensive, severe, or recalcitrant disease if sites affected are difficult to treat, e.g. face, palms, or genitalia further counselling, education, or demonstration of topical application Consider using Person-Centred Dermatological Care Index (PeDeSI) to assist in the education and support needs of the patient. if psoriasis is causing significant disability psoriasis in children diagnosis is in doubt. Assessment and confirmation of diagnosis 2,6 Perform holistic assessment including: family history 50% of patients have an affected relative duration of symptoms possible triggers, e.g. infection, especially streptococcal; skin trauma; medications, including lithium, chloroquine, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs) alcohol previous treatments and responses articular symptoms vascular risk comorbidities (diabetes mellitus, hypertension, coronary heart disease, inflammatory bowel disease, lymphoma) Assess degree of disability: psychological and social (the effect of this is frequently underestimated): screen for depression refer to mental health services appropriately consider using a validated tool to assess degree of disability and severity of disease tools include: Dermatology Life Quality Index (DLQI) Psoriasis Area and Severity Index (PASI) Psoriasis Epidemiology Screening Tool (PEST) Examine for clinical features: typical skin lesions - well circumscribed, slightly raised plaques with a silvery scale typical sites of skin involvement elbows, knees, legs, lower back, scalp, penis, ears, palms, soles of feet, nails nail involvement is common signs include pitting, onycholysis and hyperkeratosis types and clinical manifestations plaque psoriasis (most common), guttate psoriasis (often triggered by tonsillitis; generalised distribution), flexural psoriasis (affects genitocrural, navel, axillary, submammary areas and ears), pustular psoriasis (sterile pustules typically involving the palms and soles of feet) erythrodermic: severe generalised form of psoriasis may be pustular, often refractory to treatment. General points: pattern of psoriasis may change from one type to another within an individual plaques may change from stable to inflammatory forms typically follows a chronic course, with periods of relapse and remission extent can vary from minimal to almost complete involvement of the skin surface.

6 Treatment options 2,6 General considerations: education and communication are pivotal encourage patients to be actively involved in managing their care advise patients to: exercise regularly manage their weight, i.e. aim for body mass index (BMI) moderate alcohol consumption stop smoking it is recommended that patients are provided with a plan (verbal and written) explaining: therapeutic options for each site benefits and potential adverse effects of treatments method of applying topical treatments ideally demonstrate techniques all patients suspected as having psoriatic arthritis should be assessed by a rheumatologist so that an early diagnosis can be made and joint damage can be reduced healthcare professionals should be aware of the need to consider comorbid conditions in patients with psoriasis and psoriatic arthritis. systemic treatment or phototherapy patients are typically considered to need systemic therapy when they have: psoriasis involving more than 10% of the body surface, or Psoriasis Area and Severity Index (PASI) or DLQI scores 10. Ensure the involvement of a multidisciplinary team (MDT) as required, including: dermatologist dermatology nurse pharmacist allied health professionals (AHPs) occupational therapist psychologist Consider inpatient management for severe cases, eg erythrodermic, severe generalized or pustular.

7 Topical therapy and review 2 Education of patients in use of their topical therapies is essential to ensure active involvement of patients in their care and optimal use of treatment. Regular emollient use should be encouraged to reduce scaling and symptoms of itch. Review should be arranged in 8-12 weeks. Consider alternative therapies for non-responders. Phototherapy and review 2 Pre and Post PASI and DLQI scores for clinical evaluation are recommended. Patients with widespread disease who do not respond to topical therapy should be offered narrow band UVB (NBUVB). PUVA photochemotherapy should be considered for patients not responding to NBUVB. Annual skin cancer screening is recommended for all patients who have received >200 whole-body PUVA treatments and/or > 500 whole-body UVB treatments. Systemic therapies and review 2 Consider systemic therapy for patients with severe or refractory psoriasis discuss benefits and risks due to adverse effects. Systemic therapies are indicated in addition to topical treatment: for widespread or disabling psoriasis for psoriasis refractory to topical therapies and/or phototherapy where multiple hospital admissions are required for anti-inflammatory, antiproliferative, and immunosuppressive effects are not always suitable for patients with erythrodermic or generalised pustular psoriasis. Review and Measure Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) every weeks assess efficacy of systemic therapies. Suggest joining the British Association of Dermatologists Biologic Interventions Register (BADBIR) to monitor long term safety. Non Responder (10 24 weeks) 1,2,5 If an adequate response has not been demonstrated at week (depending on therapy), consider modifying therapy. Such modification may be adjustment of topical therapy dose, addition of another treatment (combination therapy) or switching to another therapy. Adequate response is defined by: 5 75% reduction in PASI score; or 50% reduction in PASI score and DLQI score of 5 points or less.

8 Responder 1,2 Measure Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) to establish adequate response, defined as: 1 75% reduction in PASI score; or 50% reduction in PASI score and 5-point reduction in DLQI from when treatment started. Continue treatment, share care with GP if appropriate (10-24 weeks) 1 Patients with psoriasis or psoriatic arthritis should have an annual review with their GP involving the following: documentation of severity using DLQI screening for depression assessment of vascular risk (in patients with severe disease) assessment of articular symptoms optimisation of topical therapy consideration for referral to secondary care.

9 References 1. National Institute for Clinical Excellence (NICE). NICE guidance on biologic drugs for the treatment of psoriasis. January SIGN. SIGN Guideline 121, Diagnosis and management of psoriasis and psoriatic arthritis in adults Pathirana D et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. JEADV, 2009;23(suppl 2): Smith CH et al. British Association of Dermatologists guidelines for biologic interventions for psoriasis. BJD, 09;161: Mrowietz U et al. Definition of treatment goals for moderate to severe psoriasis: a European consensus. Arch Dermatol Res, 2 011;303: Map of Medicine. Psoriasis - suspected. October National Institute for Clinical Excellence (NICE). Adalimumab for the treatment of adults with psoriasis. June NICE technology appraisal guidance National Institute for Clinical Excellence (NICE). Etanercept and efalizumab for the treatment of adults with psoriasis. July NICE technology appraisal guidance National Institute for Clinical Excellence (NICE). Infliximab for the treatment of adults with psoriasis. January NICE technology appraisal guidance Mrowietz U et al. A consensus report on appropriate treatment optimization and transitioning in the management of moderate-to-severe plaque psoriasis. JEADV 2014;28,

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