What are alternative treatments for a 58-year-old female with treatment-resistant plaque psoriasis after Otezla (apremilast) is denied by insurance?

From the Guidelines

For a 58-year-old female with treatment-resistant plaque psoriasis after Otezla denial, the most effective alternative treatment option is etanercept (Enbrel, 50mg twice weekly for 12 weeks, then 50mg weekly) as recommended by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics 1.

Alternative Treatment Options

Other treatment options can be considered, including:

• Topical therapies such as high-potency corticosteroids (clobetasol 0.05% cream twice daily for 2-4 weeks) or vitamin D analogs (calcipotriene 0.005% ointment twice daily)
• Phototherapy, particularly narrowband UVB treatments 2-3 times weekly for 10-12 weeks
• Systemic options like methotrexate (starting at 7.5mg weekly, potentially increasing to 15-25mg weekly), cyclosporine (2.5-5mg/kg/day divided into two doses), or acitretin (10-25mg daily)
• Biologics such as adalimumab (Humira, 40mg every other week), ustekinumab (Stelara, weight-based dosing), secukinumab (Cosentyx), or ixekizumab (Taltz) may be considered, though insurance approval may require documented failure of other therapies 1

Considerations

It is essential to note that the patient should also consider appealing the Otezla denial with her physician's help, as insurance companies sometimes reverse decisions with proper documentation of medical necessity. The British Association of Dermatologists' guidelines for biologic interventions for psoriasis 2009 also provide guidance on the use of biologics for the treatment of moderate to severe chronic plaque psoriasis 1.

Key Points

• Etanercept is recommended as a monotherapy treatment option for adult patients with moderate-to-severe plaque psoriasis 1
• The recommended starting dose of etanercept is 50 mg taken as a self-administered subcutaneous injection twice weekly for 12 consecutive weeks 1
• Combination of etanercept and topicals, such as high-potency corticosteroids with or without a vitamin D analogue, is recommended as a treatment option to augment efficacy for the treatment of moderate-to-severe plaque psoriasis 1

From the FDA Drug Label

The safety and effectiveness of STELARA ®have been established for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for phototherapy or systemic therapy.

Two multicenter, randomized, double-blind, placebo-controlled trials (Ps STUDY 1 and Ps STUDY 2) enrolled a total of 1996 subjects 18 years of age and older with plaque psoriasis who had a minimum body surface area involvement of 10%, and Psoriasis Area and Severity Index (PASI) score ≥12, and who were candidates for phototherapy or systemic therapy

Alternative treatments for a 58-year-old female with treatment-resistant plaque psoriasis after Otezla (apremilast) is denied by insurance may include:

• Ustekinumab (STELARA): a human IgG1κ monoclonal antibody that binds with specificity to the p40 protein subunit used by both the IL-12 and IL-23 cytokines.
• Other biologic therapies that target different pathways involved in the pathogenesis of psoriasis, such as TNF-α inhibitors, IL-17 inhibitors, or IL-23 inhibitors.
• Systemic therapies such as methotrexate, cyclosporine, or acitretin.
• Phototherapy with UVB or PUVA.

It is essential to consult a healthcare professional to determine the best course of treatment for this patient, considering her medical history, current condition, and insurance coverage 2, 2.

From the Research

Alternative Treatments for Plaque Psoriasis

After Otezla (apremilast) is denied by insurance, several alternative treatments can be considered for a 58-year-old female with treatment-resistant plaque psoriasis.

• Biologic Treatments: Biologics such as infliximab, bimekizumab, ixekizumab, and risankizumab have shown high efficacy in achieving PASI 90, a measure of clear or almost clear skin, compared to placebo 3, 4.
• Non-Biological Systemic Agents: Non-biological systemic agents such as methotrexate and ciclosporin can be considered as alternative treatments, although their efficacy may be lower compared to biologics 3, 4.
• Combination Therapy: Combination therapy with biologics such as guselkumab and adalimumab may be effective in treating refractory plaque-type psoriasis and psoriatic arthritis, although more studies are needed to evaluate the efficacy and safety of this approach 5.
• Topical Therapies: Topical corticosteroids and vitamin D analogues can be considered as alternative treatments, although their efficacy may be lower compared to systemic treatments. Topical corticosteroids may be less irritating at the site of application compared to vitamin D analogues 6.

Considerations for Treatment Selection

When selecting an alternative treatment, several factors should be considered, including:

• Efficacy: The effectiveness of the treatment in achieving PASI 90 and improving quality of life.
• Safety: The risk of serious adverse events (SAEs) and other safety concerns associated with the treatment.
• Cost: The cost of the treatment and whether it is covered by insurance.
• Patient Preferences: The patient's preferences and values, including their willingness to accept potential risks and benefits associated with the treatment.