(Brand Name: Otezla)

What it does / How it works

Apremilast is an immunosuppressant that comes in an oral tablet. Apremilast reduces the activity of phosphodiesterase 4 (PDE4), an enzyme that regulates inflammation in the skin and joints. Apremilast can help to clear plaques, reduce itch, improve nail psoriasis, and clear scalp psoriasis.

Time frame

Patients can expect to see symptom improvement within 4 months of starting treatment. The length of treatment may vary, and it is important to follow your doctor’s instructions carefully. 

Dosage Form

Apremilast is available as an oral tablet.

Dose and frequency

The usual maintenance dose is 30 mg twice a day. It may be started at a lower dose and titrated up over time to minimize the risk of side effects such as nausea, diarrhea, and stomach upset. 

Potential Side Effects

Common side effects include diarrhea, nausea, vomiting, headache, and upper respiratory tract infections (e.g. common cold). Rarely, this medication can decrease appetite, worsen depression, and cause weight loss.

How to manage side effects

Side effects such as nausea, diarrhea, and stomach upset usually resolve within the first month of treatment. The medication should be swallowed whole, with or without food. 

Monitoring and follow up

Your doctor may assess your kidney function before starting treatment as a lower dose may be required for patients with severe kidney impairment. Your doctor may also monitor your weight regularly during treatment. 

Cost considerations

Apremilast is not covered in most provinces. 

See public insurance for more details

(Neoral)

What it does / How it works

Cyclosporine is an immunosuppressant that works by blocking the release of certain “cytokines” which are signalling molecules that play a role in inflammation. In psoriasis, cytokines are involved in triggering the body to attack its own healthy cells. Doctors usually prescribe cyclosporine for patients with severe flares or when psoriasis rebounds after other treatments. It often clears the skin rapidly. Due to the risk of side effects, its use is often limited to short term treatment.  

Time frame

Cyclosporine is usually taken for 12 to 16 weeks. After discontinuation of cyclosporine, another maintenance treatment is started to prevent relapse.

Dosage Form

Cyclosporine is available as an oral solution and capsule. 

Dose and frequency

The usual initial dose is 2.5 to 3mg/kg/day given twice a day (12 hours apart) for about 4 weeks. It may be started at a lower dose and titrated up over time to minimize the risk of side effects. Dose adjustments should be made in increments of 0.5 to 1.0 mg/kg/day. These are general guidelines and patients should always follow the directions provided by their doctor.

Potential Side Effects

Common side effects include headache, vomiting, diarrhea, muscle cramps, high cholesterol, and fatigue.

Patients taking cyclosporine may be at an increased risk of infections. Talk with your doctor or pharmacist about what vaccines may be recommended for you. 

This medication can cause damage to the kidneys if used for long periods of time. Therefore, cyclosporine is usually limited to short courses and is not usually taken for longer than a year or two, at most. Lab tests should be done regularly to monitor kidney function during treatment.

Patients may develop high blood pressure while taking cyclosporine. This can be treated with antihypertensive medications. Elevated blood pressure caused by cyclosporine use is usually reversible upon stopping the drug.

Patients should not use phototherapy during treatment with cyclosporine due to the increased risk of skin cancer.

How to manage side effects

Cyclosporine can interact with some prescription and over the counter medications leading to increased side effects including kidney damage. Your pharmacist can help you understand, manage, and prevent these interactions. Ongoing monitoring of kidney function and blood pressure is required to avoid permanent kidney damage and chronic hypertension. Due to the severity of certain side effects, long-term use of cyclosporine for psoriasis is not usually recommended.

Monitoring and follow up

Pre-treatment physical examination usually includes evaluation of blood pressure, kidney function and careful examination for tumours, particularly of the skin, to establish accurate baseline values and clinical status. Your doctor may monitor your kidney function and blood pressure during treatment. Routine blood tests are prescribed to monitor metabolic problems such as too much magnesium or uric acid in the blood.

Cost considerations

Cyclosporine may require special authorization in some provinces before it can be covered by the provincial drug plan. Talk to your doctor or pharmacist about coverage options.

See public insurance for more details.

What it does / How it works

Methotrexate works by blocking the ability of cells to divide. This can affect all your cells but in psoriasis patients, it can target the parts of your immune system that are over-activated and triggering the symptoms of psoriasis. By suppressing the immune system, it can reduce symptoms of redness, scaling, burning, stinging, cracking, flaking, and pain. 

Time frame

Most people start to see treatment benefits about a month after starting methotrexate. Dose changes can take about a month to take effect. In some, methotrexate can be very effective as a long-term treatment to prevent flares and control symptoms.

Dosage Form

Methotrexate comes in an oral tablet formulation and as a vial for injection into the muscle or fatty tissue.

Dose and frequency

Methotrexate can be taken weekly as a single dose or 3 doses over 24 hours (spaced at 12 hour intervals). Dose schedules may be gradually adjusted to achieve optimal clinical response. The usual methotrexate dose for psoriasis is 7.5mg to 25 mg per week up to a maximum of 30 mg/week. Take methotrexate as directed by your doctor for optimal dosing.

Potential Side Effects

Common side effects include nausea, anorexia, mouth ulcers and tiredness. More serious side effects include liver, kidney, lung, and bone marrow problems. Methotrexate can also cause fetal death or birth defects involving the limbs and brain. Patients should ensure they are not pregnant before starting methotrexate and should consider methods of contraception while taking methotrexate. Patients looking to get pregnant after stopping methotrexate should consult their physician before doing so.

Although effective in many patients, methotrexate may increase your risk of infection because it suppresses the immune system. Vaccines can help to reduce your risk of certain infections. Talk to your doctor or pharmacist for more information.

How to manage side effects

Taking this medication with food can help to minimize side effects such as upset stomach, nausea, and diarrhea. Taking folic acid can also help. Folic acid is usually given daily except on the day methotrexate is taken. Taking folic acid or folinic acid can help to reduce side effects such as upset stomach, nausea, and diarrhea. Folic acid and folinic acid are considered equally efficacious but folic acid is usually less expensive.  

Some prescription and over the counter medications may interact with methotrexate and increase the risk of adverse reactions. Your doctor or pharmacist can help you manage or prevent these interactions.  

Monitoring and follow up

Prior to treatment, clinical and laboratory evaluation should be done to evaluate pre-existing hepatitis virus B and hepatitis virus C infection. Methotrexate is not recommended for patients with active or chronic hepatitis B or C infection. 

Liver function tests should be performed several times prior to dosing and periodic blood tests should be done to check for liver problems and other side effects. Periodic liver biopsies may be recommended for patients undergoing long-term treatment. 

Cost considerations

Methotrexate is eligible for coverage under your provincial drug plan. Talk to your pharmacist for details.

See public insurance for more details

What it does / How it works

Oral retinoids, such as acitretin, are derived from vitamin A. They are usually reserved for the treatment of severe psoriasis that covers more than 10% of the body or causes physical, occupational, or psychological disability. They are particularly helpful for palm and sole psoriasis. Oral retinoids are often combined with UVB or PUVA phototherapy and biologic therapy for greater benefits.

These medications work by slowing the growth of skin cells, preventing skin from swelling, and interrupting the body’s attack on itself. When combined with other agents, they work synergistically, enabling the use of lower doses of each drug. 

Time frame

Patients may notice some improvement in their symptoms 2 weeks after starting the medication. It may take 3 to 6 months to see the full effect of treatment.

Dosage Form

Oral capsule

Dose and frequency

The usual daily dose ranges from 10mg to 50mg. Starting with a low dose and titrating up slowly until the desired effect is reached can help to ensure the lowest effective dose is used. 

Potential Side Effects

Potential side effects include eye, mouth or nose dryness, nosebleeds, dry skin, swollen or cracked lips, brittle nails, hair loss, nausea, stomach-ache, muscle or joint pain, pins-and-needle sensations and itchy, burning, or sticky skin. Hair loss is rare but can be more common with high doses such as those exceeding 17.5mg per day.

Due to the risk of birth defects, oral retinoids must not be used by pregnant women. Women of childbearing age should ensure they use a reliable form of contraception while taking an oral retinoid. Because the drug persists for long periods in the body, women should avoid becoming pregnant while taking acitretin and for a full three years after they have stopped taking it. Acitretin should also be avoided while breastfeeding. 

How to manage side effects

Side effects are minimized by using the lowest effective dose.

Monitoring and follow up

Pregnancy tests must be performed before and during treatment and up to 3 years after the last dose. Routine blood tests are used to monitor cholesterol and triglyceride levels as well as liver and kidney function. Your doctor may also conduct regular checkups to monitor for vision problems or bone abnormalities.

Drug interactions are possible with other psoriasis medications—such as cyclosporine—and patients must avoid supplements that contain vitamin A to prevent overdose.

Cost considerations

Acitretin may require special authorization before it is covered by your provincial drug plan. Talk to your pharmacist for more information.

 See public insurance for more details.