From the Guidelines
Conventional DMARDs for psoriasis have several important contraindications that clinicians must consider before prescribing, including pregnancy, breastfeeding, alcoholism, significant liver disease, bone marrow suppression, and renal insufficiency for methotrexate, as well as uncontrolled hypertension, significant renal impairment, active infection, and malignancy for cyclosporine. The contraindications for conventional DMARDs can be broken down by medication:
- Methotrexate is contraindicated in:
- Pregnancy
- Breastfeeding
- Alcoholism
- Significant liver disease
- Bone marrow suppression
- Renal insufficiency as stated in the guidelines of care for the management of psoriasis and psoriatic arthritis: section 4 1
- Cyclosporine should be avoided in patients with:
- Uncontrolled hypertension
- Significant renal impairment
- Active infection
- Malignancy as outlined in the guidelines for management of patients with psoriasis 1
- Acitretin is absolutely contraindicated in:
- Pregnancy (category X)
- Women of childbearing potential who cannot guarantee contraception for 3 years after discontinuation due to its teratogenic effects and long half-life, as noted in the guidelines of care for the management of psoriasis and psoriatic arthritis: section 1 1 For all conventional DMARDs, active serious infections represent a contraindication due to their immunosuppressive effects, and regular monitoring is essential when using these medications, including complete blood counts, liver function tests, and renal function tests 1. The specific contraindication profile of each DMARD relates to its mechanism of action and metabolism, with methotrexate affecting folate metabolism and being hepatotoxic, cyclosporine affecting renal function, and retinoids like acitretin having profound teratogenic effects due to their influence on embryonic development. Key points to consider when prescribing conventional DMARDs for psoriasis include:
- Careful patient selection based on contraindications and potential drug interactions
- Regular monitoring of laboratory tests, including complete blood counts, liver function tests, and renal function tests
- Patient education on the potential risks and benefits of treatment, as well as the importance of adherence to prescribed regimens.
From the FDA Drug Label
Cyclosporine [MODIFIED] is contraindicated in patients with a hypersensitivity to cyclosporine or to any of the ingredients of the formulation. Rheumatoid arthritis patients with abnormal renal function, uncontrolled hypertension, or malignancies should not receive cyclosporine [MODIFIED]. Psoriasis patients who are treated with cyclosporine [MODIFIED] should not receive concomitant PUVA or UVB therapy, methotrexate or other immunosuppressive agents, coal tar or radiation therapy. Psoriasis patients with abnormal renal function, uncontrolled hypertension, or malignancies should not receive cyclosporine [MODIFIED]. Methotrexate has been reported to cause fetal death and/or congenital anomalies. Therefore, it is not recommended for women of childbearing potential unless there is clear medical evidence that the benefits can be expected to outweigh the considered risks Pregnant women with psoriasis or rheumatoid arthritis should not receive methotrexate
The typical contraindications for conventional DMARDs for psoriasis are:
- Hypersensitivity to the drug or its ingredients
- Abnormal renal function
- Uncontrolled hypertension
- Malignancies
- Pregnancy or childbearing potential without clear medical evidence of benefits outweighing risks
- Concomitant use of other immunosuppressive agents, such as PUVA or UVB therapy, methotrexate, coal tar, or radiation therapy 2, 3
From the Research
Contraindications for Conventional DMARDs in Psoriasis
- There are no specific studies provided that directly address the typical contraindications for conventional DMARDs in psoriasis.
- However, studies 4, 5, 6 discuss the use of conventional DMARDs in rheumatoid arthritis, which may have some relevance to psoriasis treatment.
- Conventional DMARDs such as methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine are commonly used in the treatment of rheumatoid arthritis and may be used in psoriasis treatment as well.
- The safety of long-term use of these DMARDs is a concern, and patients should be monitored closely for potential side effects such as hepatotoxicity 5, 6.
- Study 7 discusses the use of tumor necrosis factor inhibitors in combination with other treatments for psoriasis, but does not specifically address contraindications for conventional DMARDs.
- Study 8 compares the efficacy of novel DMARDs as monotherapy and in combination with methotrexate in rheumatoid arthritis patients, but does not provide information on contraindications.