for psoriasis and psoriatic arthritis including biologics

> Cyclosporine > Adalimumab > Golimumab > Methotrexate > Alefacept > Infliximab > Acitretin > Etanercept > + more

systemic medications

introduction to psoriasis
what is psoriasis?
Psoriasis is a noncontagious, genetic disease of the immune system that affects the skin and/or joints. According to the National Institutes of Health, as many as 7.5 million Americans have psoriasis. The most common form, plaque psoriasis, results in raised, red lesions covered by silvery white scales. Psoriasis can be limited to a few lesions or can involve moderate to large areas of skin. Having 3 to 10 percent of the body affected by psoriasis is generally considered to be a moderate case. More than 10 percent is considered severe. For most individuals, the palm of the hand is about the same as 1 percent of the skin surface. However, the severity of psoriasis can also be measured by how psoriasis affects a person’s quality of life. Psoriasis can have a serious impact even if it involves a small area, such as the palms of the hands or soles of the feet.

are prescription drugs that affect the entire body. They are usually used for individuals with moderate to severe psoriasis and psoriatic arthritis. Systemic medications are also used in those who are not responsive to or are unable to take topical medications or ultraviolet (UV) light. These drugs are taken by mouth in liquid or pill form or given by injection. This booklet covers two kinds of systemics. The first, traditional systemics, have been used for more than 10 years. The other is a relatively new class of treatments for psoriasis and psoriatic arthritis, the biologics.

SyStemic medicAtionS

traditional systemics
Cyclosporine
What is it and how does it work? Cyclosporine is an immunosuppressive drug that was first used to help prevent rejection in organ transplant patients. In 1997, the U.S. Food and Drug Administration (FDA) approved Neoral (one brand name for cyclosporine) for psoriasis. It is used in adults with severe psoriasis and otherwise normal immune systems. Cyclosporine suppresses the immune system and stops the actions of certain immune cells. This slows the growth of skin cells.

Up to 30 percent of individuals with psoriasis also develop psoriatic arthritis, which causes pain, stiffness and
swelling in and around the joints. To learn more about the types of psoriasis or psoriatic arthritis, visit the National Psoriasis Foundation Web site at www.psoriasis.org.

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How is it used? Cyclosporine is taken daily by mouth. It is available as a capsule or a liquid. The liquid form must be diluted for use. It is preferably mixed with room temperature orange or apple juice (not grapefruit juice; see page 4 for more on drug interactions). Individuals should take cyclosporine on a consistent schedule. Cyclosporine can provide rapid relief from symptoms. Individuals may see some improvement in symptoms after two weeks of treatment, particularly with stronger doses. However, it may take from three to four months to reach a more complete level of control.

• Individuals with malignancies, or a history of malignancies (other than basal or squamous cell skin cancers) • Individuals who are undergoing radiation treatment • Individuals with severe gout

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xtended use of cyclosporine by transplant patients is well-established. However, longterm use as a treatment for psoriasis is more limited. The FDA recommends the drug not be used for longer than one year. However, there are no specific guidelines for how long individuals should stay off cyclosporine before resuming treatment with the drug. Some doctors may prescribe the drug for more than one year.

Who should not take cyclosporine? • Individuals whose immune systems are compromised (for example, anyone with lymphoma or HIV infection, or individuals receiving other immune-suppressing drugs) • Women who are breastfeeding • Individuals with abnormal kidney function • Individuals with high blood pressure

What are the risks? Individuals previously treated with PUVA (the light-sensitizing drug psoralen plus ultraviolet light A), methotrexate or other immunosuppressive agents, ultraviolet light B (UVB), coal tar or radiation therapy are at an increased risk of developing skin malignancies when taking cyclosporine. Renal dysfunction, including kidney damage, is a potential risk of cyclosporine. This increases with length of time and amount of cyclosporine taken. The risk is further increased in individuals with kidney damage already present. Your doctor will monitor your kidney function with blood tests before and during treatment with cyclosporine. Patients can also develop hypertension on this medication so blood pressure must be closely monitored. accinations may be less effective if taken while on cyclosporine. Talk to your doctor if you plan to get any kind of vaccination. Cyclosporine should be used during pregnancy only if the potential benefits outweigh the potential risks. In general, women are advised not to become pregnant while taking cyclosporine. Your doctor may recommend that if you do become pregnant while taking cyclosporine, you should stop the treatment.

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What are the side effects? Possible side effects from taking cyclosporine include: • Decreased kidney function • Headache • High blood pressure • High cholesterol • Excessive hair growth • Tingling or burning sensations in the arms or legs • Skin sensitivity • Increased growth of gum tissues • Flu-like symptoms • Upset stomach • Tiredness • Muscle, bone or joint pain

Over-the-counter (OTC) medications such as aspirin and ibuprofen can also interact with cyclosporine. These interactions could affect the metabolism of the drug. This causes you to have either too much or too little of the drug in your bloodstream. void drinking grapefruit juice or eating grapefruit while taking cyclosporine. This can increase levels of the drug in the blood. Eating a potassium-rich diet while on cyclosporine can raise the level of potassium in the blood. This could be harmful. Talk to your doctor about the amount of potassium-rich foods such as bananas, tomatoes, raisins and carrots you may have in your diet. St. John’s Wort, a popular dietary supplement used for treating depression, can reduce the blood levels of cyclosporine in transplant patients. It is not clear if the dose of cyclosporine used in treating psoriasis would be affected by St. John’s Wort. Talk to your doctor about taking St. John’s Wort while on cyclosporine. can it be used with other treatments? Cyclosporine can be used with the topical vitamin D drugs calcipotriene and calcitriol (brand names Dovonex and Vectical). These are safe and effective for severe chronic plaque psoriasis. When using caclipotriene or calcitriol along with cyclosporine leads to improvement, a lower dosage of cyclosporine can be given. This lessens the risk of side effects. our doctor may recommend alternating cyclosporine with other forms of treatment to manage psoriasis better. This is called rotational therapy.

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Generally, these side effects go away with a lower dose or if the drug is stopped. What are the potential drug interactions? Your doctor should always be aware of any other medications, treatments or dietary supplements you are using. Many medications interact with cyclosporine. Some of these are certain antibiotics, anti-inflammatories, anti-fungals, gastrointestinal agents, calcium channel blockers and anti-convulsants.

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Cyclosporine treatment should not normally be combined with PUVA, UVB therapy, methotrexate or other immunosuppressive agents. Protect your skin while in the sun and avoid too much exposure.

Methotrexate
What is it and how does it work? Methotrexate is in a class of medications known as anti-metabolites. It was initially used to treat cancer. Methotrexate was found to be effective in clearing psoriasis in the 1950s. In the 1970s, it was approved for this use by the FDA. It is usually sold as a generic. The doses administered for cancer are considerably higher than the doses given for psoriasis and psoriatic arthritis.

drug. If it is tolerated, the dosage is increased to achieve clearance. Once the skin is clear, the dose may be gradually reduced to the lowest level capable of keeping a reasonable improvement. If doing well, a person may be taken off methotrexate until symptoms return. However, some individuals must continue a maintenance dose to keep up clearance. If a few stubborn lesions remain, usually a doctor will not increase the dose of methotrexate. Instead, another treatment, such as a topical treatment, may be added to clear the remaining lesions. Improvement from methotrexate usually begins within three to six weeks of starting this drug. Individuals may not see maximal improvement for up to six months. Who should not take methotrexate? • Individuals with alcoholism, alcoholic liver disease or other chronic liver diseases such as cirrhosis • Individuals with immunodeficiency syndromes • Pregnant or nursing mothers • Men or women attempting a pregnancy • Individuals with active peptic ulcers • Individuals with significant liver or kidney abnormalities • Individuals with active infectious disease • Individuals with pre-existing blood problems such as underdevelopment of bone marrow, low white blood cell count, low platelets or significant anemia

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ethotrexate is indicated for use in adults with severe psoriasis. In addition, the drug can be used to treat psoriatic arthritis. Methotrexate can be highly effective in reducing the painful symptoms of psoriatic arthritis. Methotrexate binds to and inhibits an enzyme involved in the rapid growth of cells. In individuals with psoriasis, the drug slows down the rate of skin cell growth.

How is it used? Methotrexate is taken once a week, either by mouth or by injection. It is most commonly taken orally, either in pill or liquid form. The liquid form may be mixed with fruit juice. The drug can be taken in a single dose or three doses taken at 12-hour intervals over a period of 24 hours. Sometimes a test dose of methotrexate is given first to see if the person tolerates the

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What are the risks? The main risk of long-term methotrexate treatment is liver damage. A small number of individuals, generally estimated to be one out of 200, will develop reversible liver scarring. This means after methotrexate is stopped, the liver will return to normal. This is a risk after a cumulative dose of 1.5 grams (g). How long it takes to reach 1.5 g depends on the person’s dose, treatment schedule and rest periods from the drug. In rare instances, some patients develop irreversible cirrhosis. The risk can be minimized by monitoring for liver toxicity at regular intervals and by avoiding medications that are known to be toxic to the liver. When a person reaches a cumulative dose of 1 g to 1.5 g, doctors may perform a liver biopsy to test for liver damage or consult a liver specialist for an opinion. Talk to your doctor about how this affects your treatment regimen. In a biopsy, a thin needle is inserted through the skin to take out a small sample of liver tissue. If significant liver damage has developed, methotrexate is usually discontinued.

Pregnancy should be avoided if either partner is taking methotrexate. Men should be off methotrexate at least three months before a couple tries to conceive. Women should wait at least four months after stopping methotrexate to become pregnant. What are the side effects? Other possible side effects include: • Nausea • Tiredness • Difficulty sleeping • Lightheadedness • Mouth ulcers • Vomiting • Headache • Easy bruising and bleeding • Fever • Diarrhea with blood in the stool • Chills • Sensitivity to sunlight

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iver biopsies are repeated at regular intervals. The risk of liver damage can increase if a person drinks alcohol, has abnormal kidney function, is obese, has diabetes or has had prior liver disease.

Individuals taking methotrexate need to have regular blood tests. This is to ensure that the drug is being safely processed by the body. This also makes sure that the liver, blood or bone marrow is not negatively affected. Methotrexate can cause a reduced white blood cell count. This can make a person more at risk for infection.

• Burning sensation in lesions • Hair loss

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hese side effects are generally manageable with careful monitoring and education.

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However, severe nausea or sores in the mouth could mean that the dose is too high. In rare instances, some side effects may occur years after the drug is used. This includes certain types of cancer, such as lymphoma, and bone marrow toxicity. Taking folic acid can decrease the side effects of methotrexate during treatment. However, folic acid should not be taken on the same days that methotrexate is taken. There is evidence that taking folic acid, even if only on days between methotrexate doses, can reduce the effectiveness of methotrexate. Your doctor will know the best schedule for taking folic acid, so talk to your doctor about folic acid supplements. What are the potential drug interactions? Your doctor should always be aware of any other medications, therapies or dietary supplements you are using. This is especially important when taking methotrexate. Medications for inflammation or pain (including aspirin and ibuprofen) may increase the effects of methotrexate, which could be harmful.

On rare occasions, sensitivity to light can occur even when methotrexate is taken several days after exposure to ultraviolet light. This is called a “sunburn recall.” can it be used with other treatments? Methotrexate is sometimes rotated with other treatments such as PUVA, acitretin (brand name Soriatane) or cyclosporine. This may decrease side effects or get better results. Methotrexate can be used with PUVA or UVB to reduce the amount of ultraviolet light needed to clear the skin. In unresponsive cases of generalized pustular psoriasis, methotrexate has been used with either acitretin or cyclosporine. It has also been used with some biologics to decrease the side effects of each medication or get better results.

Acitretin
What is it and how does it work? Acitretin is an oral retinoid, which is a synthetic form of vitamin A. Synthetic retinoids were approved in the United States in the 1980s. Soriatane (a brand name) is the only oral retinoid approved by the FDA specifically for treating psoriasis. Isotretinoin (brand name Accutane) is another oral retinoid that is sometimes used instead of acitretin to treat psoriasis (see page 16 for more about this treatment).

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ome oral antibiotics can interfere with the absorption of methotrexate. Penicillin can reduce clearance of the drug from the kidneys. Talk to your doctor before taking any of these drugs with methotrexate. Individuals are best advised not to drink alcohol while on a course of methotrexate because it increases the chance of liver damage. Sulfa drugs, especially those containing trimethoprim (brand names Septra or Bactrim), also should not be taken while on methotrexate. The interaction of sulfa drugs and methotrexate can be fatal.

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he exact way acitretin works to control psoriasis is unknown. In general, retinoids affect how cells regulate their behavior. Retinoids help control the multiplication of cells. This includes the speed at which skin cells will grow and shed from the skin’s surface, which speeds up in psoriasis.

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How is it used? Acitretin comes in 10 milligram (mg) and 25 mg capsules. The prescribed dose is taken once a day and should be taken with food. Several factors determine the dosage for each individual, including the type of psoriasis present. Doses may be reduced after symptoms improve, depending on the person’s response. Ordinarily, retinoid treatment is stopped when lesions have cleared significantly. When lesions or other symptoms reappear, the drug may be taken again. Acitretin tends to work slowly for plaque psoriasis. Psoriasis may worsen before individuals start to see clearing. After eight to 16 weeks of treatment, the skin lesions usually will improve. It may take up to six months for the drug to reach its peak effect. Acitretin is indicated for use in adults with severe psoriasis. The acitretin label supports the use of the drug for plaque, guttate, pustular, erythrodermic and palmoplantar psoriasis. Who should not take acitretin? • Pregnant women or women who might become pregnant during treatment • Women who are breastfeeding

What are the risks? The most serious is the risk of severe birth defects in developing fetuses if the mother has the drug in her body during pregnancy. Acitretin can remain in the body for many months, so acitretin is not to be taken for three years before pregnancy. Because of the risk of birth defects, women of child-bearing potential must have two negative pregnancy tests before starting acitretin. They must use two effective forms of birth control at least one month before beginning treatment, while on the drug and for three years after stopping treatment. Women who become pregnant during the three years following treatment should seek the advice of a doctor who specializes in high-risk pregnancies. Progestin-only birth control pills may not work while taking acitretin, so women should avoid using them as a primary form of birth control.

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ndividuals should not donate blood during treatment and for three years after stopping treatment. Donated blood could expose pregnant women to acitretin.

What are the possible side effects? • Hair loss • Chapped lips and dry mouth • Dry skin and dry eyes • Bleeding gums and nose bleeds

• Individuals with severe liver or kidney disease • Individuals with repeated high levels of fat in the blood that cannot be controlled with other medications • Individuals who are allergic to or have hypersensitivity to retinoids
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• Increased sensitivity to sunlight • Peeling fingertips and nail changes • Changes in blood fat levels • Depression

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• Aggressive thoughts or thoughts of selfharm • Headache • Joint pain • Decreased night vision • Elevated liver enzymes

can it be used with other treatments? Acitretin is most effective for treating psoriasis when it is used with phototherapy rather than by itself. Combination therapy can speed clearing and help reduce the amount of phototherapy needed to clear symptoms. This reduces the risks and side effects of both treatments. Acitretin is sometimes used with the biologic drugs alefacept, etanercept and infliximab to achieve clearing of psoriasis. Acitretin may also be prescribed in rotation with other systemic medications, such as cyclosporine or methotrexate.

These side effects, and others, seem to be dose dependent. This means they tend to go away after stopping the medication or lowering the dosage. What are the potential drug interactions? Your doctor should always be aware of any other medications, therapies or supplements you are using. Avoid dietary supplements with vitamin A. Acitretin is related to vitamin A, and taking vitamin A could add to the unwanted effects of acitretin. omen of childbearing potential who use acitretin must not drink or eat any substance containing alcohol during treatment and for two months after treatment is stopped. Alcohol can cause acitretin to convert to a form that is only slowly removed from the body. This increases the risk of birth defects if the woman becomes pregnant. Acitretin can reduce the effectiveness of phenytoin, a common drug for epilepsy, when given concurrently. Acitretin should not be combined with tetracycline (an antibiotic), since both medications can cause increased pressure on the brain, which can have serious consequences.

other systemic medications
The following systemic medications are not approved by the FDA for the treatment of psoriasis or psoriatic arthritis. However, some doctors prescribe them “off-label”—a common and accepted medical practice.

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Anti-malarial therapy
Anti-malarial therapy is sometimes used to treat psoriatic arthritis. Certain anti-malarial drugs, namely chloroquine, may trigger psoriasis symptoms in some individuals, so talk to your doctor about this treatment option.

Hydroxyurea
Hydroxyurea (also known by its brand name Hydrea) is an oral cancer medication that, in the late 1960s, was found to be effective for psoriasis. Although not as effective as methotrexate, it is less likely to cause liver damage with long-term use. While fewer individuals will have an acceptable response than with methotrexate, hydroxyurea can produce significant improvement in stable

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plaque psoriasis in about half of the subjects who tolerate it. The major side effect of hydroxyurea is bone marrow toxicity. If this develops, it can occur quite rapidly and so it is important to monitor closely, especially in the first several months. Long-term use has been associated with skin cancer.

psoriasis. Because it can suppress the immune system, people with compromised immune systems should not take it.

Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs can help relieve pain, swelling and stiffness of psoriatic arthritis. NSAIDs are available in over-the-counter and prescription strengths. Examples of OTC NSAIDs include aspirin, ibuprofen (Advil, Motrin) and naproxen sodium (Aleve). If you feel the need to take frequent doses of over-the-counter NSAIDs to control your arthritis, you may need to move to prescription-strength medications. Because psoriatic arthritis can cause permanent joint damage, an evaluation by a rheumatologist may also be indicated.

Isotretinoin
Isotretinoin (also known by its brand name Accutane) is an oral retinoid (a synthetic form of vitamin A ) that was approved as a treatment for severe cystic acne. However, some doctors have used it successfully to treat severe psoriasis. Generally, it is not as effective as acitretin for psoriasis.

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sotretinoin has many side effects similar to acitretin (see discussion of acitretin on page 11). The most common side effects are eye and lip dryness and nosebleeds. Bone spurs and hair loss occur to a lesser degree. Isotretinoin leaves the body much faster than acitretin, and some doctors consider it safer for women of childbearing potential. However, it also can cause severe birth defects if a woman becomes pregnant while the drug is in her system. A woman on isotretinoin should use reliable birth control one month before treatment, during treatment and for at least one month after stopping treatment.

Sulfasalazine
A combination anti-inflammatory and antibiotic, sulfasalazine is sometimes used in treating psoriatic arthritis. It is generally regarded as being only modestly effective in plaque psoriasis. Many clinicians think that methotrexate is more effective than sulfasalazine. However, sulfasalazine’s side effects tend to be less dangerous. Therefore, trying this medication may be worthwhile for some. Many people cannot tolerate sulfasalazine because of allergy to sulfa or because of side effects, including nausea, vomiting and loss of appetite.

Mycophenolate mofetil
Mycophenolate mofetil has been used to prevent organ transplant rejection. It has also been used for several inflammatory or autoimmune skin diseases. It can be used in combination with cyclosporine, and some doctors use it when tapering patients off cyclosporine. Many physicians believe that it is not very effective as a stand-alone treatment for

6-Thioguanine
6-Thioguanine is an oral medication approved for treating certain types of leukemia. It is effective for plaque psoriasis, including the treatment of pustular psoriasis. 6-Thioguanine also requires close medical supervision due to potential severe side effects, including

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suppression of the bone marrow. Most who use it feel that it works as often and as well as methotrexate.

biologic treatments
The biologics are a relatively new class of prescription psoriasis and psoriatic arthritis treatments. They are given by injection into the skin or muscle or through intravenous (IV) infusion.

What are they and how do they work?
A biologic is a drug or vaccine that comes from living sources, such as human or animal proteins. Biologics have been around for more than 100 years. However, they have been used only recently for psoriasis and psoriatic arthritis. It is now believed that all systemic treatments that work for psoriasis and psoriatic arthritis affect the immune system in some way. Methotrexate and cyclosporine have a broad impact on the immune system and can potentially cause serious side effects in other organs. The biologics, however, are specific in targeting the immune system. This lessens the effect of the drugs on the rest of the body, although their long-term effects are still being evaluated.

to work by blocking the activation of T cells, though it also works by eliminating them. T cells are a type of white blood cell in the body. Typically, they help the body rid itself of foreign invaders such as viruses, fungi and bacteria. In psoriasis, processes that are not completely understood activate some T cells. These T cells then travel to the skin. Once in the skin, they respond as though they were fighting an infection or healing a wound. This sets off a chain of events that leads to the rapid growth of skin cells. This causes lesions to form and become inflamed.

Tumor necrosis factor-alpha blockers
Four biologic medications—etanercept (brand name Enbrel), adalimumab (brand name Humira), golimumab (brand name Simponi) and infliximab (brand name Remicade)—block tumor necrosis factor-alpha (TNF-alpha). TNFalpha is a chemical messenger or cytokine of the immune system that causes cells to release other proteins that add to the inflammatory process. In psoriasis and psoriatic arthritis, there is excess production of TNF-alpha in the skin or joints. This leads to the rapid growth of skin cells typical of psoriasis, or to the joint inflammation characterized by stiffness, pain, warmth and redness seen in psoriatic arthritis. The decline in TNF-alpha, a critical regulator of inflammation, stops the inflammatory cycle of psoriasis and psoriatic arthritis.

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iologics act by blocking the action of certain immune cells or chemical messengers that play a role in psoriasis and psoriatic arthritis. There are currently two types of biologics for these diseases:

How are they used?
The biologics are taken by injection or by intravenous (IV) infusion. Alefacept is injected into the muscle in a doctor’s office. Typically, individuals give themselves injections of etanercept, adalimumab and golimumab at home. The injections are given in a manner similar to how individuals with diabetes give

T cell-directed agent
Alefacept (brand name Amevive) was designed

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themselves insulin injections. Infliximab is given through IV infusion in a doctor’s office or an infusion center.

side effects and risks. These should be weighed carefully against the risks of other treatment options.

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octors are most likely to recommend biologics for individuals with moderate to severe cases of psoriasis and psoriatic arthritis. The biologics offer a promising option for individuals who have not responded to other treatments. They offer an option for those who have experienced harmful side effects from other treatments or who cannot take some medications because of those side effects. Biologics can be very effective at improving psoriasis and psoriatic arthritis. However, how well they work will vary for individuals. Three drugs—etanercept, adalimumab and infliximab—have been shown in clinical trials to decrease progressive joint damage in psoriatic arthritis.

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ecause the biologics suppress the immune system, there could be an increased risk of infection. Caution is advised for the elderly, due to the already increased risk of infection for this age group. Individuals who develop any sign of an infection should contact their doctor right away.

Who should not take biologics?
• Individuals whose immune systems are already significantly compromised • Individuals with active infections • Individuals with active tuberculosis or those with a positive TB test who have not been treated with a course of isoniazid (INH) as recommended by American Thoracic Society guidelines

The impact of biologics in pregnant women or developing fetuses is not known. It is not known if the drug passes into breast milk in nursing women. Biologics should only be given to pregnant or nursing women if there is a clear medical need. It is a decision the doctor and the individual need to make together. Pregnant women using biologics should talk to their doctor about enrolling in a pregnancy registry.

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he Food and Drug Administration has reviewed the link between TNF-alpha medications and an increased risk of developing lymphoma, a type of cancer. The FDA concluded there is not enough data to know if these drugs added to the higher risk of lymphoma.

What are the side effects?
The side effects for biologic medications vary. Common side effects for biologics include: • Respiratory infections • Flu-like symptoms • Injection site reactions (such as swelling, itch or rash) for self-injected biologics

What are the risks?
Biologics for psoriasis and psoriatic arthritis are still relatively new. As such, their overall safety is still being evaluated. Anyone considering these agents should talk with his or her doctor about the short- and long-term

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These side effects are generally mild and in most cases do not cause individuals to stop taking the medication. You should tell your doctor about any side effect that bothers you or does not go away.

Alefacept (Amevive)
• FDA-approved for treating psoriasis • Preliminary studies showed that alefacept has a modest but positive effect on psoriatic arthritis • Given by an injection in the muscle in a doctor’s office once per week for 12 weeks • Additional 12-week treatment cycles might be necessary or recommended • Blood tests required every two weeks during treatment to monitor immune cell counts

Can they be used with other treatments?
All of the current biologics can and have been used with other psoriasis treatments, such as phototherapy or topicals. Some data suggest that phototherapy in combination with alefacept may improve the outcome. If you have had phototherapy, taking infliximab may increase your risk of skin cancer. Etanercept, infliximab, golimumab and adalimumab are safe and effective when taken with methotrexate. Some people have seen success using acitretin with different biologics. Talk to your doctor about whether using any other treatments with a biologic is right for you.

Etanercept (Enbrel)
• FDA-approved for treating psoriasis, psoriatic arthritis, juvenile idiopathic arthritis, rheumatoid arthritis and ankylosing spondylitis • Patients give themselves an injection under the skin once or twice a week • Taken continuously to maintain results • Patients should be screened for latent (hidden) tuberculosis (TB) before taking etanercept • May reduce the progression of joint damage • Occasional blood tests are recommended

Adalimumab (Humira)
• FDA-approved for treating psoriasis, psoriatic arthritis, ankylosing spondylitis and rheumatoid arthritis • Individuals give themselves an injection under the skin usually every other week • Patients should be screened for latent (hidden) tuberculosis (TB) before taking adalimumab • May reduce the progression of joint damage • Occasional blood tests are recommended

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Golimumab (Simponi)
• FDA-approved for treating psoriatic arthritis, ankylosing spondylitis and rheumatoid arthritis • Patients give themselves an injection under the skin once per month • Patients should be screened for latent (hidden) tuberculosis (TB) before taking golimumab • May reduce the progression of joint damage

Take charge of your health— join today!
Whether you’re newly diagnosed or have been coping with psoriasis/psoriatic arthritis for years, the National Psoriasis Foundation offers something for everyone. Your donation of $35 or more brings you these membership benefits:
• Psoriasis Advance: Keep up to date with the latest psoriasis news in our award-winning magazine. • Money-saving coupons and discounts: Receive exclusive coupons for skin care and other health products. • Treatment tips: Full access to It Works for Me, our online database of tips from people with psoriasis and psoriatic arthritis. • Toll-free information line: Call between 8 a.m. and 5 p.m. Pacific Time and talk to our health educator. • Opportunities to connect: Share information and support with others who have the disease through our online message board and affiliated support groups. • Help in finding a doctor, special invitations to educational events and more!

Infliximab (Remicade)
• FDA-approved for psoriasis, psoriatic arthritis, rheumatoid arthritis, ulcerative colitis, ankylosing spondylitis and Crohn’s disease • Given by three infusions in a doctor’s office during the first six weeks of treatment • Later infusions repeated every eight weeks • Patients should be screened for latent (hidden) tuberculosis (TB) before taking infliximab • May reduce the progression of joint damage • Blood tests are recommended on a regular basis

To join the National Psoriasis Foundation call 800.723.9166 or go to www.psoriasis.org.

Additional resources
The National Psoriasis Foundation maintains an extensive library of information on psoriasis and related topics. To learn more, visit our Web site at www.psoriasis.org or e-mail education@psoriasis.org.

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for psoriasis and psoriatic arthritis including biologics
mission statement To find a cure for psoriasis and psoriatic arthritis and to eliminate their devastating effects through research, advocacy and education.
The National Psoriasis Foundation, a charitable 501(c)(3) organization, depends on your tax-deductible donations to support the millions of people diagnosed with psoriasis and/or psoriatic arthritis. The Psoriasis Foundation is governed by a volunteer Board of Trustees and is advised on medical issues by a volunteer Medical Board. For more information, or to obtain a copy of the Foundation’s Annual Report, call 800.723.9166. National Psoriasis Foundation educational materials are reviewed by members of our Medical Board and are not intended to replace the counsel of a physician. The Psoriasis Foundation does not endorse any medications, products or treatments for psoriasis or psoriatic arthritis and advises you to consult a physician before initiating any treatment. ©2009 National Psoriasis Foundation

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National Psoriasis Foundation
6600 SW 92nd Ave., Suite 300 Portland, OR 97223-7195 Toll Free 800.723.9166 www.psoriasis.org

August 2009