What are the considerations for using apremilast (phosphodiesterase 4 inhibitor) to treat psoriasis in an elderly patient with potential impaired renal function and history of psychiatric disorders?

Apremilast Workup for Psoriasis in Elderly Patients

Apremilast is an excellent choice for elderly psoriasis patients, particularly those with renal impairment or psychiatric history, because it requires minimal laboratory monitoring and has a favorable safety profile in this population. 1, 2, 3

Pre-Treatment Assessment

Essential Baseline Evaluations

• Renal function assessment (serum creatinine/creatinine clearance) is the single most important baseline test, as dose adjustment to 30 mg once daily is mandatory if creatinine clearance is <30 mL/min 1, 4, 5

• Baseline weight measurement should be documented, as weight loss >5% from baseline may necessitate discontinuation 1, 6, 4

• Depression screening is critical given the patient's psychiatric history; apremilast carries a 1% risk of depression and may worsen pre-existing depressive symptoms 1, 6, 4

• Medication review to identify strong CYP450 inducers (rifampin, phenobarbital, carbamazepine, phenytoin) that would reduce apremilast efficacy 1, 4

What You Do NOT Need

• No routine laboratory monitoring is required—no CBC, liver function tests, or lipid panels 1, 4

• No liver biopsy or hepatic function assessment is needed, as apremilast does not cause hepatotoxicity despite hepatic metabolism 4

• This contrasts sharply with methotrexate, which requires extensive monitoring in elderly patients 1

Dosing Protocol

Standard Titration Schedule

• Use the mandatory 5-day titration schedule starting at 10 mg on day 1, increasing to 30 mg twice daily by day 6 to minimize gastrointestinal side effects 1, 6, 7

Renal Impairment Adjustment

• If creatinine clearance <30 mL/min, reduce maintenance dose to 30 mg once daily (not twice daily) 1, 4, 5

• No dose adjustment is needed for mild-to-moderate renal impairment 5

Ongoing Monitoring Requirements

What to Monitor at Each Visit

• Body weight at every visit; discontinue if weight loss exceeds 5% from baseline 1, 6, 4

• Depression screening at each visit, particularly in the first few months of therapy 1, 6, 4

• Hydration status in elderly patients, as they are particularly prone to dehydration from gastrointestinal effects and may require hospitalization 4

What NOT to Monitor

• No routine laboratory tests are needed—avoid ordering "just to be safe" as this adds unnecessary cost and patient burden 4

• No blood pressure or creatinine monitoring is required (unlike cyclosporine) 1

Managing Common Side Effects in the Elderly

Gastrointestinal Effects (Most Common)

• Diarrhea and nausea occur in 70-80% of patients within the first 2 weeks, with 75-80% being mild and 60-65% resolving within the first month 1, 6, 4

• Counsel patients before starting that GI symptoms are expected, temporary, and manageable 6, 8

• Elderly patients require closer monitoring for dehydration due to diarrhea 4

Weight Loss

• 12% of patients experience 5-10% weight loss (vs. 5% on placebo) 1, 4

• This is particularly concerning in frail elderly patients who may already have marginal nutritional status 4

Psychiatric Considerations

• Depression occurs in approximately 1% of patients 1, 4

• Given the patient's psychiatric history, establish clear monitoring protocols and consider involving psychiatry if symptoms emerge 6, 4

Why Apremilast is Ideal for Elderly Patients

Advantages Over Other Systemic Therapies

• No immunosuppression risk, unlike biologics or conventional DMARDs, making it safer in elderly patients with age-related immune dysfunction 2, 3

• Low risk of drug interactions despite CYP450 metabolism, which is advantageous given polypharmacy in elderly patients 1, 2, 3

• Safe in patients with serious comorbidities including chronic infections, malignancy history, and hepatic disease—conditions that would contraindicate other systemic therapies 9

• Oral administration eliminates injection-related barriers in patients with limited mobility or needle phobia 3

Evidence in Elderly Populations

• Biologics and apremilast are well-tolerated in older adults and more effective than conventional systemic therapies 2, 3

• No increased frequency or severity of adverse events have been documented in elderly patients with serious baseline comorbidities 9

Expected Timeline for Response

• Early onset of action with significantly improved outcomes after only 2 weeks of treatment 7

• Full assessment of efficacy should occur at 16 weeks, consistent with other systemic psoriasis therapies 1

Common Pitfalls to Avoid

• Do not order routine labs "for monitoring"—this is unnecessary and contradicts guideline recommendations 4

• Do not forget renal dose adjustment in severe renal impairment; this is the only required dose modification 1, 4, 5

• Do not dismiss early GI symptoms as intolerable—counsel patients that these typically resolve within the first month 6, 8

• Do not use apremilast with strong CYP450 inducers as this will reduce efficacy 1, 4

Position in Treatment Algorithm

Apremilast is appropriate as first-line systemic therapy in elderly patients, particularly when:

• Patient prefers oral therapy over injections 1, 6
• Patient cannot undergo regular laboratory monitoring due to access barriers 4
• Patient has contraindications to biologics (recurrent infections, congestive heart failure, demyelinating disease) 1
• Patient has hepatic or renal disease that would complicate methotrexate or cyclosporine use 1, 4

However, biologics (TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors) remain more efficacious and should be considered if the patient can tolerate parenteral administration and has severe disease requiring maximal efficacy 1, 3