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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_404"
                     title="Tailor Etanercept to Symptoms in Psoriasis and Psoriatic Arthritis (CME/CE)"
                     score="0.009"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18309?impressionId=1265767891611"
                     
      &lt;p&gt;The decision to use once-weekly or twice-weekly etanercept (Enbrel) in patients with both psoriasis and psoriatic arthritis should be determined by the cutaneous and joint symptoms of the patient, researchers said.&lt;/p&gt;
&lt;p&gt;In a blinded, multicenter study, 46% of patients who received the drug twice a week had cleared or almost cleared their skin manifestations of psoriasis at week 12, compared with 32% of those who received the drug only once each week (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Wolfram Sterry, MD, of Charite University Medicine in Berlin, and colleagues.&lt;/p&gt;
&lt;p&gt;In contrast, there were no differences in response for arthritis symptoms, with 77% of those in the twice-weekly group and 76% of those in the once-weekly group meeting predetermined psoriatic arthritis response criteria at week 12, the researchers reported online in the &lt;em&gt;BMJ&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;An estimated 30% of patients with psoriasis have an arthritic component to their disease, manifesting as chronic inflammation of the joints and entheses.&lt;/p&gt;
&lt;p&gt;&quot;The challenge of treating patients with both active psoriasis and active psoriatic arthritis is to optimize the treatment of both disease manifestations to give the best overall outcome,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;Etanercept, a fully human tumor necrosis factor (TNF) inhibitor, is approved for use in both conditions based on findings showing that TNF and other cytokines are upregulated in both inflamed joint and skin tissues.&lt;/p&gt;
&lt;p&gt;To determine the efficacy of two different treatment regimens in patients who had not previously received a TNF inhibitor but had moderate-to-severe skin symptoms and active arthritis, Sterry and colleagues recruited 752 patients from 98 centers for PRESTA (Psoriasis Randomized Etanercept STudy in subjects with psoriatic Arthritis).&lt;/p&gt;
&lt;p&gt;They paired rheumatologists and dermatologists to cooperatively assess effects of the drug.&lt;/p&gt;
&lt;p&gt;Patients were randomized to receive subcutaneous etanercept, 50 mg once or twice weekly for 12 weeks, and for an additional 12 weeks both groups received 50 mg once weekly.&lt;/p&gt;
&lt;p&gt;To maintain blinding, the once-weekly group also received a placebo injection during the first 12 weeks.&lt;/p&gt;
&lt;p&gt;Participants&apos; mean age was 46.5 years. Mean duration of psoriasis was 18.9 years, and mean duration of arthritis was seven years. Most were white men.&lt;/p&gt;
&lt;p&gt;For the joint symptoms, the proportions of patients who achieved American College of Rheumatology (ACR) responses were similar at weeks 12 and 24 in the two groups.&lt;/p&gt;
&lt;p&gt;At week 12, 66.4% and 60.8% of patients in the twice- and once-weekly groups, respectively, had achieved ACR20 responses (representing a 20% improvement). At week 24, the corresponding proportions were 69% and 71.7%.&lt;/p&gt;
&lt;p&gt;At week 12, the percentage reductions in physician&apos;s global assessment of arthritis were 60% and 62% for the twice- and once-weekly groups (&lt;em&gt;P&lt;/em&gt;=0.823), and at week 24 the corresponding percentages were 73% and 74% (&lt;em&gt;P&lt;/em&gt;=0.760).&lt;/p&gt;
&lt;p&gt;At baseline, enthesitis was found in 287 patients and dactylitis in 318. These two symptoms decreased comparatively in both groups at weeks 12 and 24.&lt;/p&gt;
&lt;p&gt;Skin findings included the following for the twice-weekly and once-weekly groups, respectively: &lt;ul&gt; &lt;li&gt;Improvement in physician&apos;s global assessment at week 12, 52% versus 45%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001&lt;/li&gt; &lt;li&gt;At week 24, 57% versus 55%, &lt;em&gt;P&lt;/em&gt;=0.420&lt;/li&gt; &lt;li&gt;Improvement in psoriasis area and severity index at week 12, 71% versus 62%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001&lt;/li&gt; &lt;li&gt;At week 24, 78% versus 74%, &lt;em&gt;P&lt;/em&gt;=0.110&lt;/li&gt; &lt;li&gt;75% improvement in psoriasis area and severity index at week 12, 55% versus 36%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001&lt;/li&gt; &lt;li&gt;At week 24, 70% versus 62%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.026&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Clearly there were differences in the optimal dosages for the skin lesions at week 12, but when the dosage was decreased to once weekly for the two groups, improvements in both joint and skin symptoms continued to improve, and at week 24 the responses were similar in the two groups, the investigators observed.&lt;/p&gt;
&lt;p&gt;&quot;We found that initial treatment of the psoriasis with etanercept 50 mg twice weekly may allow for more rapid clearance of skin lesions than a 50 mg weekly regimen,&quot; they wrote, noting that the higher dose therefore may be preferable for patients with more severe cutaneous involvement.&lt;/p&gt;
&lt;p&gt;In contrast, at no time was the twice-weekly regimen more effective in treating the articular symptoms, so 50 mg once weekly is a sufficient dose for the treatment of joint symptoms alone, they concluded.&lt;/p&gt;
&lt;p&gt;There were no differences in safety between the regimens.&lt;/p&gt;
&lt;p&gt;It is not clear why the higher dose cleared the skin symptoms more rapidly than the low dose but did not have an additional benefit for the joint symptoms.&lt;/p&gt;
&lt;p&gt;&quot;These two different organ systems may have dissimilar autoimmune inflammatory environments, allowing for differences in local concentrations of tumor necrosis factor or in disease burdens or a subtle difference in tissue penetration of drug, although little information is available to support any particular mechanism,&quot; the researchers noted.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Wyeth Research, which was acquired by Pfizer in October 2009, sponsored the trial.&lt;/p&gt;&lt;p&gt;Authors and sponsor were involved in study design, interpretation of data, manuscript preparation, and decision to publish.&lt;/p&gt;&lt;p&gt;Statistical analyses were done by the biostatistics department of Wyeth Research.&lt;/p&gt;&lt;p&gt;Several co-authors are employees of Pfizer, and others have received fees from multiple pharmaceutical companies including Wyeth.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_190"
                     title="Rising Costs -- the Real Heartbreak of Psoriasis (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/Dermatology/Psoriasis/tb/18028?impressionId=1265767891611"
                     
      &lt;p&gt;The heartbreak of psoriasis used to be the disease itself. Now it&apos;s the skyrocketing cost of treatment.&lt;/p&gt;
&lt;p&gt;From 2000 through 2008, the cost of brand-name drugs increased 66% on average, according to Vivianne Beyer, MD, and Stephen Wolverton, MD, of the Indiana University School of Medicine in Indianapolis (Beyer is currently at St. Vincent Hospital in Indianapolis).&lt;/p&gt;
&lt;p&gt;The cost of several of the drugs &quot;greatly outpaced&quot; both general inflation and the overall increase in cost of prescription medicines, the researchers reported in the January issue of &lt;em&gt;Archives of Dermatology.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;The disease, a chronic autoimmune illness, affects between 4.5 million and 7.5 million people in the U.S., the researchers noted.&lt;/p&gt;
&lt;p&gt;Up to a third of those do not respond to topical therapy. However, more effective systemic treatments appear to be underused, they said  --  perhaps in part because of cost, a major issue with newer biologic drugs.&lt;/p&gt;
&lt;p&gt;Analysis showed that current annual costs ranged from $1,197 for methotrexate (Rheumatrex, Trexall), at 7.5 milligrams a week, to $27,577 for two 12-week courses of alefacept (Amevive).&lt;/p&gt;
&lt;p&gt;Phototherapy costs ranged from $3,083 for a year of UV-B therapy to $7,288 annually for psoralen-UV-A treatment, including induction and maintenance.&lt;/p&gt;
&lt;p&gt;Acitretin (Soriatane) at 25 milligrams a day cost $9,163, comparable to the $9,999 for 400 milligrams daily of cyclosporine. But some patients need twice the dose of acitretin, which increases the annual cost to $17,613, the researchers said.&lt;/p&gt;
&lt;p&gt;The annual costs of the biologics used to treat psoriasis ranged from $18,384 to $27,577, but those requiring a loading dose  --  such as adalimumab (Humira) and infliximab (Remicade)  --  were more costly during the first year of treatment than in following years, they said.&lt;/p&gt;
&lt;p&gt;To obtain information about trends, the researchers compared year-over-year average wholesale prices for the various treatments.&lt;/p&gt;
&lt;p&gt;They found that percentage changes in drug prices between 2000 and 2008 ranged from a drop of 24.1% for methotrexate to an increase of 316% for the brand-name version of methoxsalen  --  Oxsoralen-Ultra.&lt;/p&gt;
&lt;p&gt;The second-largest increase was 157.5% for acitretin, they said.&lt;/p&gt;
&lt;p&gt;The biologics also increased in price, but not all were available for the entire period. For example, the cost of efalizumab (Raptiva) increased by 35.1% over a four-year period, while adalimumab&apos;s cost increased by 27.2% during a five-year interval, the researchers said.&lt;/p&gt;
&lt;p&gt;On average the increase was 66%, they said, which is markedly higher than inflation. Over the same period, the consumer price index-urban for all items rose 25.8%, and 30.1% for prescription drugs.&lt;/p&gt;
&lt;p&gt;The researchers did not include indirect costs, such as time away from work, direct costs such as inpatient care, or costs that arose because of adverse effects.&lt;/p&gt;
&lt;p&gt;One clinical implication of the findings is that physicians should consider cost as well as efficacy and tolerability when prescribing drugs for psoriasis, the researchers concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers did not report external support for the study. Wolverton reported financial links with Eli Lilly and Amgen.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_1634"
                     title="ICD: Aloe Vera Shows Promise for Psoriasis"
                     score="-0.006"
                     href="http://www.medpagetoday.com/Dermatology/ICD/tb/14382?impressionId=1265767891611"
                     
       PRAGUE, May 26 -- Patients with plaque psoriasis had a greater reduction in disease activity when treated with topical aloe vera compared with a topical steroid, data from a randomized trial demonstrated. 
              &lt;p&gt;&lt;p&gt;Patients treated with aloe vera had a significantly greater reduction in the Psoriasis Area and Severity Index (PASI) after eight weeks of treatment, Charoen Choonhakarn, M.D., of Khon Kaen University in Khon Kaen, Thailand, and colleagues reported here at the International Congress of Dermatology. 
              &lt;p&gt;The difference did not achieve statistical significance, but the magnitude of change from baseline to eight weeks differed significantly in an adjusted analysis. 
              &lt;p&gt;The advantage demonstrated in the study landed in a middle ground between two previous studies that produced conflicting results. 
              &lt;p&gt;&quot;Although contrary results were reported from two previous placebo-controlled studies, our study showed that aloe vera cream was more effective than 0.1% triamcinolone acetonide cream after eight weeks of treatment,&quot; the investigators concluded. 
              &lt;p&gt;&quot;The between-group difference in adjusted means was statistically significant,&quot; they added. &quot;Thus, aloe vera cream can be considered a safe alternative treatment for mild to moderate chronic plaque psoriasis.&quot; 
              &lt;p&gt;Topical steroids remain central to most management strategies for psoriasis, but chronic use poses a risk of local and systemic adverse effects. 
              &lt;p&gt;A systematic review of clinical applications of topical aloe vera suggested the agent is helpful in psoriasis (&lt;em&gt;Br J Gen Pract&lt;/em&gt; 1999; 49: 823-28). However, two small placebo-controlled clinical trials conducted a decade apart yielded widely disparate results, one showing a clear advantage for aloe vera and the other a significant placebo advantage (&lt;em&gt;Trop Med Int Health&lt;/em&gt; 1996; 1: 505-09, &lt;em&gt;J Eur Acad Dermatol Venereol&lt;/em&gt; 2005; 19: 326-31). 
              &lt;p&gt;In the current study, Dr. Choonhakarn and colleagues evaluated aloe vera and an active comparator. The study involved 80 patients who had a baseline PASI score of about 11. 
              &lt;p&gt;The patients were randomized to 70% aloe vera cream or 0.1% triamcinolone acetonide. The primary outcome was the change in PASI score from baseline to eight weeks. 
              &lt;p&gt;At the end of the study, the PASI score decreased by an average of 7.7 points in the aloe vera group and 6.6 in the patients treated with the topical steroid. The difference was statistically significant (&lt;em&gt;P&lt;/em&gt;=0.0237), although the 95% confidence intervals crossed 1.0 (2.13 to -0.16). 
              &lt;p&gt;The change in disease-related quality of life scores did not differ significantly between groups. 
              &lt;p&gt;No patient in either group had complete clearance of psoriasis lesions. 
              &lt;p&gt;Six patients (16.2%) in the aloe vera group had PASI 75 responses compared with four (10.5%) in the steroid group. 
              &lt;p&gt;More patients treated with the topical steroid had PASI 50 responses (66% versus 54%). 
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt; The study was supported by Khon Kaen University. 
              &lt;p&gt;The authors reported no disclosures. &lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_1645"
                     title="ICD: Palmoplantar Psoriasis Responds to Retinoid"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/ICD/tb/14392?impressionId=1265767891611"
                     
      PRAGUE, May 27 -- Treatment with the oral vitamin A derivative acitretin (Soriatane) led to measurable improvement in 100% of patients with palmoplantar psoriasis in a small clinical series reported here. 
              &lt;p&gt;
              &lt;p&gt;Among patients who completed three months of follow-up, the mean Psoriasis Area and Severity Index (PASI) score declined from 11 at baseline to 1.65, Krupa Shankar, M.D., of Manipal Hospital in Bangalore, India, told attendees at the International Congress of Dermatology. 
              &lt;p&gt;
              &lt;p&gt;Dry skin was the most common adverse effect associated with acitretin. A quarter of patients had moderate elevation of triglycerides that were controlled with lipid-lowering therapy. 
              &lt;p&gt;
              &lt;p&gt;&quot;All of the patients in the study showed good results clinically and reported improvement in quality of life,&quot; said Dr. Shankar. &quot;The results suggest that oral acitretin is a useful option for the treatment of palmoplantar psoriasis.&quot; 
              &lt;p&gt;
              &lt;p&gt;The findings came from an evaluation of the vitamin D analog in 45 patients with mild or moderate psoriasis involving the hands and feet who ranged in age from 28 to 66. 
              &lt;p&gt;
              &lt;p&gt;Investigators excluded patients with abnormal liver function tests or lipid levels, women of reproductive age, and individuals on other systemic or topical therapies for psoriasis. 
              &lt;p&gt;
              &lt;p&gt;The patients received an acitretin dose of 0.5 mg/kg/day for three months and were evaluated monthly by means of clinical photographs and a modified PASI. Liver function tests and lipid profile were evaluated at baseline and at each monthly follow-up visit. 
              &lt;p&gt;
              &lt;p&gt;The modified disease index assumed a score of 0 for the head and trunk, and evaluation of extremities was limited to the palms and soles of the feet. Total possible score ranged from 0 to 72. 
              &lt;p&gt;
              &lt;p&gt;Dr. Shankar reported that 36 patients completed the first month of follow-up, 28 patients the second, and 25 the third. Five patients discontinued before taking the first dose of acitretin. 
              &lt;p&gt;
              &lt;p&gt;Among patients who attended the first follow-up visit, the mean PASI score decreased from 11 at baseline to 6.5. The average score decreased to 3.4 at the second follow-up visit and to 1.65 among patients who remained in the study through the final follow-up. 
              &lt;p&gt;
              &lt;p&gt;Dr. Shankar said 35 patients developed dry skin, and 27 had cheilitis. Both conditions improved with topical skin-care regimens. 
              &lt;p&gt;
              &lt;p&gt;Moderate triglyceride elevations of 160 to 273 mg/dL were seen in 10 patients. Eight were treated with fenofibrate, and the number of patients with elevated triglycerides decreased to three at the second and third follow-up visits, including two of the patients who received fenofibrate. 
              &lt;p&gt;
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;Dr. Shankar reported that he had no disclosures. &lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
         
    </recommendedItem>
    <recommendedItem id="20090101_19_1646"
                     title="ICD: Cytokine Levels May Offer Psoriasis Clues"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/ICD/tb/14394?impressionId=1265767891611"
                     
      PRAGUE, May 27 -- Monitoring cytokine levels in patients with psoriasis may offer an early indication of response to therapy, according to data reported here. 
              &lt;p&gt;
              &lt;p&gt;In patients with psoriasis, tumor necrosis factor-alpha (TNF-&amp;#945;) and interleukin 6 (IL-6) were significantly elevated at baseline, and levels of TNF-&amp;#945;, IL-4, and IL-6 declined significantly with effective treatment, Ram Chander, M.D., of Lady Hardinge Medical College in New Delhi, India, said at the International Congress of Dermatology. 
              &lt;p&gt;
              &lt;p&gt;Levels of IL-10 increased during treatment, an unexplained observation that requires further study. 
              &lt;p&gt;
              &lt;p&gt;&quot;On the basis of these findings, we believe that validation of the role of cytokines in prospective, multicentric, double-blind studies is warranted,&quot; said Dr. Chander. 
              &lt;p&gt;
              &lt;p&gt;&quot;Studies also are needed to delineate the role of specific cytokines in the pathogenesis of psoriasis and thus make cytokines a more specific and predictable tool for monitoring the disease.&quot; 
              &lt;p&gt;
              &lt;p&gt;Growing use of biological agents to treat psoriasis has focused attention on the role of cytokines in the pathogenesis of the disease. Monitoring cytokine levels might help clinicians predict response to therapy and impending relapse, said Dr. Chander. 
              &lt;p&gt;
              &lt;p&gt;He and his colleagues measured serum cytokine levels in 30 patients with psoriasis (principally psoriasis vulgaris) and 30 age- and sex-matched controls without psoriasis. Baseline levels of TNF-&amp;#945;, IL-4, IL-6, and IL-10 were measured and levels in the two groups were compared. 
              &lt;p&gt;
              &lt;p&gt;The investigators also looked for associations between patients&apos; baseline cytokine levels and disease activity and assessed the effect of psoriasis therapy on cytokine levels. 
              &lt;p&gt;
              &lt;p&gt;Baseline Psoriasis Area and Severity Index (PASI) was &amp;lt;5 (mild) in four patients, 5 to 10 (moderate) in 10 patients, and &amp;gt;10 (severe) in 16 patients. The approach to treatment varied according to baseline disease severity.
              &lt;p&gt; 
              &lt;p&gt;The patients had significantly higher baseline levels of TNF-&amp;#945; and IL-6 compared with the control group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). 
              &lt;p&gt;
              &lt;p&gt;IL-4 tended to be elevated in patients versus controls but not significantly so, and the patients also tended to have lower IL-10 levels. 
              &lt;p&gt;
              &lt;p&gt;Among the psoriasis patients, the impact of treatment on cytokine levels varied by baseline severity (PASI). 
              &lt;p&gt;
              &lt;p&gt;Patients with mild disease at baseline had a significant decrease in IL-6 levels during treatment (&lt;em&gt;P&lt;/em&gt;=0.044), but the other three cytokines did not change significantly. 
              &lt;p&gt;
              &lt;p&gt;Patients with moderate baseline disease activity had significant decreases in TNF-&amp;#945; (&lt;em&gt;P&lt;/em&gt;=0.028) and IL-6 (&lt;em&gt;P&lt;/em&gt;=0.001) and a significant increase in IL-10 (&lt;em&gt;P&lt;/em&gt;=0.03) in response to therapy. 
              &lt;p&gt;
              &lt;p&gt;Patients with the most severe baseline disease activity had significant decreases in TNF-&amp;#945; (&lt;em&gt;P&lt;/em&gt;=0.004), IL-4 (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), and IL-6 (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) but no change in IL-10 from baseline. 
              &lt;p&gt;
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;Dr. Chander reported no competing interests.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
        
    </recommendedItem>
</recommendedContent>