What oral treatment options are available for a patient with severe psoriasis and schizophrenia who refuses Cosentyx (secukinumab) and topical treatments?

From the Guidelines

For a patient with severe psoriasis and schizophrenia who refuses Cosentyx and topical treatments, oral methotrexate is the most appropriate first-line systemic option, starting at 7.5-15mg once weekly, as it has good efficacy and a relatively favorable safety profile compared to other oral options, as supported by the guidelines of care for the management of psoriasis with traditional systemic agents 1.

When considering oral methotrexate, it's essential to monitor liver function and complete blood counts regularly. The patient should also be informed about potential side effects, such as nausea, vomiting, diarrhea, and malaise, and the importance of regular follow-up appointments to monitor treatment efficacy and potential adverse effects.

Other oral options, such as acitretin (25-50mg daily) and cyclosporine (2.5-5mg/kg/day divided into two doses), may also be considered, but they have more significant safety concerns and monitoring requirements. Acitretin requires monitoring for lipids and liver function, while cyclosporine is typically limited to short courses due to potential renal toxicity and hypertension.

Apremilast (30mg twice daily after titration) has a favorable safety profile with no required lab monitoring, making it a suitable option for patients with adherence concerns. However, its efficacy may be lower compared to methotrexate, and it's essential to weigh the benefits and risks of each medication when making a treatment decision.

It's also crucial to check for drug interactions with the patient's antipsychotic medications, particularly with cyclosporine, to minimize potential adverse effects. Regular follow-up appointments are essential to monitor both treatment efficacy and potential adverse effects, ensuring the best possible outcome for the patient.

Some key points to consider when treating a patient with severe psoriasis and schizophrenia include:

• Monitoring for potential drug interactions with antipsychotic medications
• Regular blood monitoring for liver function and complete blood counts with methotrexate
• Monitoring for lipids and liver function with acitretin
• Limiting cyclosporine use to short courses due to potential renal toxicity and hypertension
• Informing the patient about potential side effects and the importance of regular follow-up appointments

By prioritizing the patient's morbidity, mortality, and quality of life, and considering the most recent and highest-quality evidence, oral methotrexate is the most appropriate first-line systemic option for a patient with severe psoriasis and schizophrenia who refuses Cosentyx and topical treatments.

From the FDA Drug Label

Acitretin has been shown to be embryotoxic and/or teratogenic in rabbits, mice, and rats at oral doses of 0.6,3, and 15 mg per kg, respectively. Acitretin should be prescribed only by those who have special competence in the diagnosis and treatment of severe psoriasis, are experienced in the use of systemic retinoids, and understand the risk of teratogenicity. Acitretin should be considered only for women with severe psoriasis unresponsive to other therapies or whose clinical condition contraindicates the use of other treatments

For a patient with severe psoriasis and schizophrenia who is refusing Cosentyx and any topical treatment, oral options are available.

• Acitretin is an option for patients with severe psoriasis who are unresponsive to other therapies or whose clinical condition contraindicates the use of other treatments 2.
• However, due to the teratogenicity of acitretin, it is essential to carefully evaluate the patient's condition and ensure that they meet the necessary criteria, particularly for female patients of childbearing potential.
• It is crucial to consider the patient's schizophrenia and ensure that they can comply with the necessary precautions and monitoring required for acitretin treatment.
• Other oral options may be considered, but the provided drug label only discusses acitretin.

From the Research

Oral Treatment Options for Severe Psoriasis with Schizophrenia

• Methotrexate: a viable option for patients with severe psoriasis, including those with schizophrenia, as it can be used as monotherapy or in combination with other drugs 3, 4, 5
• Cyclosporine: another option for patients with severe psoriasis, which can be used for short courses of 3 to 4 months duration, with close monitoring of renal function and blood pressure 3, 4, 6
• Acitretin: an oral retinoid that can be used for the treatment of severe psoriasis, including palmoplantar psoriasis, with a longer duration of remission compared to methotrexate, but with more adverse events 6
• Combination therapy: the use of methotrexate and cyclosporine in combination may be effective for patients with severe, recalcitrant psoriasis, allowing for lower doses of each agent and good control of both skin and joint problems 5

Considerations for Patients with Schizophrenia

• Patients with psoriasis have a higher risk of schizophrenia, with a pooled odds ratio of 1.41 compared to those without psoriasis 7
• The treatment of psoriasis in patients with schizophrenia should take into account the potential interactions between psoriasis treatments and antipsychotic medications, as well as the patient's overall mental health status 7