10.17.09 ~ 15.15 ~ Lebwohl ~ Psoriasis Therapy Workshop

10.17.09 ~ 15.15 ~ Lebwohl ~ Psoriasis Therapy Workshop -...

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PSORIASIS Mark Lebwohl MD Mark Lebwohl, MD Sol and Clara Kest Professor And Chairman Department of Dermatology The Mount Sinai School of Medicine Methotrexate and psoriasis: 2009 National Psoriasis Foundation Consensus Conference. Kalb RE Strober B Weinstein G Kalb RE, Strober B, Weinstein G, Lebwohl M. J Am Acad Dermatol.2009;60:824-37. Baseline Monitoring • CBC + plts • BUN/Creatinine (CCl [Cockroft Gault] when indicated) • ALT, AST, Alk phos, Albumin, Bilirubin • When indicated/Optional: Hepatitis B & C serologies HIV Pregnancy test PPD Continued Monitoring • CBC + plts 7-14 d. p. dose then q2-4 w. x few mos. then q 13mos then q 1-3 mos. • BUN/Creatinine q 2-3 mos. • ALT, AST, Alk phos, Albumin q4-12 w. • When indicated: pregnancy “In patients without risk factors for hepatic fibrosis, liver biopsies may not be indicated or the fk d l d d frequency markedly reduced. 2009 NPF consensus statement Psoriasis patients with diabetes type 2 are at high risk of developing liver fibrosis during methotrexate treatment. Rosenberg P, et al J. Hepatol. 2007;46:1111-8.
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169 liver bx’s in 71 psoriasis pts on MTX • Hepatic fibrosis: 71% • In pts with risk fx: 96% obesity 14/15 diabetes 7/7 ETOH 9/9 LFT’s not associated with fibrosis Rosenberg P, et al J. Hepatol. 2007;46:1111-8. Table III. Monitoring for hepatotoxicity in low risk patients • No baseline liver biopsy Monitor liver function tests monthly for the • Monitor liver function tests monthly for the first 6 months and then every 1-2 months thereafter Table II. Risk factors for hepatic toxicity from methotrexate • History of or current excessive alcohol consumption • Persistent abnormal liver chemistry studies • History of liver disease including chronic hepatitis B or C Family history of inheritable liver diseas Family history of inheritable liver disease • Diabetes mellitus • Obesity • History of significant exposure to hepatotoxic drugs or chemicals • Lack of folate supplementation • Hyperlipidemia Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis. Van Ede A, et al. Arthritis Rheum 2001;44:1515-1524. Folate and folinic acid prevent LFT’s. Pancytopenia secondary to methotrexate therapy in rheumatoid arthritis. Gutierrez-Urena S et al. Arthritis Rheum 1996 Feb; 39(2):272-6 . 1996 Feb; 39(2):272 6. 70 cases, 12 deaths 1.4% in prospective trials Risk fx: BUN, Cr; albumin; infection; medications; age Efficacy and safety of ustekinumab , a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double- blind, placebo-controlled trial (PHOENIX 2). Papp KA,et al. Lancet. 2008;371(9625):1675-84. Efficacy and safety of ustekinumab a human interleukin Efficacy and safety of , a human interleukin- 12/23 monocl onal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1).
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10.17.09 ~ 15.15 ~ Lebwohl ~ Psoriasis Therapy Workshop -...

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