Monitoring of immunomodulatory drugs used in dermatology

Introduction

Consult the standard texts and locally approved data sheets for detailed pharmacology and therapeutic information on the immunomodulatory drugs discussed here.

Second-line drugs commonly used in dermatology (on or off label) include:

• Methotrexate

  • The dose is 5 to 30 mg once a week (orally or subcutaneous)
  • Folic acid 5 mg is also often prescribed.

• Azathioprine

  • The dose is 1-3 mg/kg/day
  • Take 1 hour before or 3 hours after food.

• Cyclosporine

  • Dosage is 2.5 to 5 mg/kg/day in 2 divided doses
  • Caution if you change brands
• TNFα inhibitors (biologics)
  • A loading dose is usual
  • A maintenance dose of etanercept is 50 mg sc every week
  • A maintenance dose of adalimumab is 40 mg sc every other week.
  • A maintenance dose of infliximab is 5 mg/kg IV every eight weeks.
  • A maintenance dose of ustekinumab is 45 or 90 mg sc every 12 weeks.
  • A maintenance dose of secukinumab is 300 mg every four weeks.

These are prescribed by specialists, but other health professionals may be involved in the patient's care. They must take into account at least the indications, contraindications, adverse effects and monitoring requirements.

Indications for immunomodulatory drugs

Immunomodulatory drugs are used for various chronic inflammatory skin conditions that are not adequately controlled in other ways. The skin disease must be serious or have a serious or functional function. psychosocial impact on the patient.

Examples of suitable conditions.

• Chronic license plate psoriasis
• Atopic eczema
• Hand dermatitis
• Chronic photosensitivity dermatitis
• Lichen planus
• Bullous pemphigoid
• Hidradenitis suppurativa
• Spontaneous Chronicle urticaria
• Drug-induced nummular dermatitis.

Pre-treatment evaluation

The patient is evaluated to determine:

• The disease is one that is expected to respond to medication.
• The extent and severity of the disease is recorded.
  • PASI score for chronic plaque psoriasis
  • SCORE or EASI for atopic eczema
• The impact of the disease is recorded.
  • DLQI (dermatological quality of life index)
• The patient wishes to receive the medication and is expected to comply with the monitoring instructions.
• Impact of patient comorbidities.
  • regular dental hygiene
• Possible contraindications to treatment.
• Vaccinations are up to date

• Vaccines may be less effective on immunosuppressants

Contraindications to treatment.

Pregnancy and lactation.

• Especially methotrexate, azathioprine

Recent vaccination with a live vaccine.

• For example, yellow fever

No immunity to varicella-zoster virus (chickenpox, shingles)

• Consider vaccination before treatment.

Non-responsive disorder

• Azathioprine is not effective for psoriasis.

• TNFα inhibitors are not effective for dermatitis or urticaria.

Comorbidities

• Methotrexate may not be suitable for patients with liver or hematological illness, or for people who drink alcohol excessively.

Hypersensitivity reactions

• Azathioprine hypersensitivity takes several forms.

Drug interactions are very common with these drugs.

• Caution if with another immunosuppressant

• Methotrexate should not be taken while on trimethoprim/sulfamethoxazole

• Azathioprine should not be taken while on allopurinol, and use caution with several other medications, including warfarin.

• Cyclosporine interacts with statins, erythromycin, itraconazole, and others.

Pretreatment tests

• Weight, height, blood pressure
• CBC, LFT, renal function
• Hepatitis b and c serology
• Sometimes: βHCG, P3NP collagen (methotrexate), thiopurine methyltransferase (azathioprine), HIV and varicella serology, TB tests
• Sometimes: chest x-ray, transient elastography scan (methotrexate)
• rarely: liver biopsy (methotrexate)

follow-up visits

Follow-up visits are to determine the effectiveness treatment and any adverse events and to monitor security.

• Treatment Efficacy
• The extent and severity of the disease is recorded.

  • PASI Score for Chronic Plaque Psoriasis

  • SCORAD or EASI for atopic eczema

• The impact of the disease is recorded.
  • DLQI
• Treatment compliance and monitoring are discussed.
• Drug interactions are checked before a new drug is prescribed.

Adverse events

Possible adverse drug events are numerous. The most common are listed here. They may require a dose reduction or discontinuation of treatment.

Methotrexate

Methotrexate:

• Nausea and other gastrointestinal symptoms.
• Mouth ulceration
• Hematologic: especially thrombocytopenia, macrocytosis
• Abnormal liver function: elevated transaminases; Hypoalbuminemia is a late effect associated with cirrhosis

Azathioprine

Azathioprine:

• Nausea and vomiting
• Abnormal liver function: cholestasis or hepatitis
• Hypersensitive reactions: eruption, lymphadenopathy
• bone marrow suppression
• susceptibility to infection including opportunistic infections
• With long-term use
  • Increased skin risk. Cancer

Cyclosporine

Cyclosporine

• Hypertension
• Renal dysfunction
• Nausea
• Ankle edema
• Shaking
• Paresthesia
• Susceptibility to infection, including opportunistic infections.
• With long-term use:
  • Increased risk of skin cancer.
  • Gingival extension
  • Hypertrichosis

Biological products

Biological products

• Injection site or infusion reactions.
• Susceptibility to infection, especially during the first year of treatment.

  • Tuberculosis and opportunistic infections.

• Various autoimmune illnesses are reported
• Secondary failure after initial response
• Increased risk of skin cancer.

security monitoring

• Weight
• Blood pressure (cyclosporine)
• CBC, LFT
• Kidney function (cyclosporine)
• Sometimes: βHCG, collagen P3NP (methotrexate)
• Sometimes: 6-thioguanine nucleotide (azathioprine)
• Sometimes: transient elastography scan (methotrexate)
• Rarely: liver biopsy (methotrexate)

People on long-term treatment with immunomodulatory drugs should undergo a full body examination in case of skin cancer.