Mark Lebwohl, MD: Let’s go on next to the new nonbiologic agent, apremilast. It appears to be quite safe. It’s a phosphodiesterase inhibitor and requires 0 blood monitoring. How often do you use it in psoriatic arthritis?
Philip J. Mease, MD: We use it in a couple of circumstances. One is for the patient who has been already on a drug like methotrexate, who is not doing well because of either effects or lack of efficacy. They’re not quite ready to move on to an injected or infused biologic medication. They’re a little nervous about adverse effects, and they love the safety profile of apremilast when they hear it.
Safety is a little different from tolerability, so there are, as you alluded to earlier, problems with potential earlier on as we use the drug: nausea, diarrhea, headache. I find that oftentimes, those symptoms go away over the first month or so, and after that, the patient is clear sailing. Then we look forward to seeing if it’s efficacious. If it is, then we don’t lose any sleep. It’s a very safe medicine, and there are 0 issues with malignancy signals and infection signals. You don’t have to do lab monitoring, so it’s a very clean drug in that regard. If it’s helpful for their arthritis and their psoriasis, then we use it in that context.
The other context is a person who has some major comorbidity that would represent a risk in taking 1 or another biologic or other targeted synthetic disease-modifying antirheumatic drugs. An example of that would be a patient who has some kind of chronic infection issue in their background, like chronic sinusitis, for example. This would be a good choice for them or for some other comorbidity, where we want a drug that has a very clean mechanism of action. Then there are occasions where the drug may be used in combination with other drugs to provide some additional benefit.
Mark Lebwohl, MD: We have almost identical remarks. We look at patients who don’t want injections, and that’s where we use it. We do use it before methotrexate. I’d say methotrexate is waning now that we have these safer drugs. The other area where I know you use it, and we do as well, is in combination for selected patients because of its safety. In combination, I get nervous about combining immunosuppressives, and I view apremilast as hardly being immunosuppressive. In fact, I don’t view it as being immunosuppressive at all.
Many years ago, when the TNF [tumor necrosis factor] blockers were primarily being used, I had a group of medical students do a review of every single case report of a malignancy or an opportunistic infection reported with biologics, and in two-thirds of the cases, it was because of combination therapy. It was usually methotrexate, steroids, or 6MP [6-mercaptopurine], so I don’t like using methotrexate with a biologic for that reason. I don’t lose any sleep over apremilast, so I actually use it in combination therapy, and more insurers are allowing it.
They are particularly allowing it if the dermatologist prescribes a biologic, the rheumatologist prescribes apremilast, or vice versa. We can get away with it, and it seems to work well. We have actually quite a few patients on combination therapy, and you probably do as well.
Transcript Edited for Clarity