Cues to Choose: How to Decide Which Psoriasis Therapy is Right for Special Populations

There are several effective systemic treatments for psoriasis, but deciding which patients may benefit can be a challenge. This is especially true when faced with a group that may not be included in a clinical trial, such as pregnant patients, patients with HIV or hepatitis, and pediatric patients. A new article in a continuing education series offers some expert opinion about which therapies might be right for these special populations.

Based on expert opinion and review of available data the authors break down the recommendations for pregnant patients as follows:
• Certolizumab is preferred because of its minimal transplacental transfer. Etanercept is a good alternative. Ustekinumab and secukinumab are considered safe, but available data are limited. Likewise, there are minimal data available on ixekizumab, brodalumab, apremilast, and IL-23 inhibitors
• Methotrexate and acitretin are absolutely contraindicated in pregnancy. Cyclosporine is an option, but its use should be limited to the shortest duration at the lowest possible dose.

Pediatric patients should take note of the following information:
• TNF-a blockers are likely safe and effective in managing pediatric psoriasis, and etanercept is approved by the FDA for the treatment of pediatric psoriasis.
• Ustekinumab is preferred due to its convenient dosing schedule; it is also approved for adolescents.
• Though none of the traditional agents (methotrexate, cyclosporine, and acitretin) are approved by the FDA for pediatric psoriasis, they are considered safe for intermittent and short-term use.
• Data on apremilast and IL-17 and IL-23 inhibitors in the pediatric population are limited.

For patients with Hepatitis (HCV and HBV) the recommendations include:
• TNF-a inhibitors can be used in patients with chronic HCV with close monitoring of liver function and viral titers, and in conjunction with antiviral therapy. In HBV the use of TNF-a inhibitors and ustekinumab can lead to viral reactivation, but IL-17 inhibitors appear safe with monitoring.
• Methotrexate is absolutely contraindicated for both HCV and HBV and for both, acitretin can be used but liver function tests must be monitored.
• Data on apremilast and IL-23 inhibitors is either limited or there is no data available.

Patients with HIV can benefit from systemic treatment of psoriasis with these recommendations:
• TNF-a inhibitors, ustekinumab, and apremilast can be used, but these patients should be managed in collaboration with infectious disease specialists.
• There are no data on IL-17 and Il-23 inhibitor use in patients with HIV.
• Acitretin can be used in patients with HIV, but methotrexate and cyclosporine should be avoided to prevent opportunistic infections.

Patients with latent tuberculosis cans safely use several agents including:
• IL-17 inhibitors, apremilast, and acitretin are safe for patients with LTBI.
• TNF-a inhibitors and ustekinumab can be used once tuberculosis prophylaxis has been initiated for at least a month. Similarly, methotrexate and cyclosporine can be used after tuberculosis prophylaxis.
• More safety data are needed for IL-23 inhibitors.