How to manage apremilast-induced gastritis in a patient with psoriasis or psoriatic arthritis?

Managing Apremilast-Induced Gastritis

Apremilast does not cause gastritis; it causes gastrointestinal symptoms (diarrhea, nausea, vomiting) that are typically self-limited and resolve within the first month without intervention. 1, 2

Understanding the GI Side Effects

The gastrointestinal symptoms associated with apremilast are not inflammatory gastritis but rather functional GI disturbances related to PDE4 inhibition:

• 70-80% of GI adverse effects occur within the first 2 weeks of treatment 1
• 75-80% are mild in severity 1
• 60-65% resolve within the first month with continued dosing and without intervention 1
• The most common symptoms are diarrhea and nausea, not gastritis 1, 2

Initial Management Strategy

Continue Current Therapy

Most patients should continue apremilast without dose modification, as symptoms typically resolve spontaneously within 4 weeks 1, 3, 4:

• Reassure the patient that symptoms are expected and usually temporary 3
• Ensure proper hydration, especially in elderly patients who are at higher risk for dehydration-related complications 1, 2
• Monitor for severe symptoms that might require hospitalization 2

Symptomatic Treatment

Provide supportive care while waiting for spontaneous resolution 3:

• Anti-diarrheal agents (e.g., loperamide) for diarrhea
• Anti-emetics for nausea
• Small, frequent meals to minimize GI distress
• Adequate fluid intake to prevent dehydration 2

When to Reduce or Discontinue

Dose Reduction

Consider reducing the dose to 30 mg once daily if symptoms are moderate but tolerable 2:

• This approach is supported by the FDA label for managing severe GI symptoms 2
• Patients generally improve quickly with dose reduction 2

Discontinuation Criteria

Discontinue apremilast if 2, 4:

• Severe diarrhea, nausea, or vomiting develops that does not improve with supportive care 2
• Chronic diarrhea persists beyond 4 weeks leading to malnutrition 4
• Hospitalization is required for GI complications 2
• The patient is elderly or taking medications causing volume depletion, making them more susceptible to complications 2

Special Populations at Higher Risk

Elderly patients (≥65 years) require closer monitoring 1, 2:

• They are more prone to dehydration from GI effects 1
• Higher risk of hospitalization from severe diarrhea, nausea, or vomiting 2
• Consider more aggressive supportive care and earlier intervention 2

Patients on medications causing volume depletion or hypotension 2:

• Monitor more frequently for complications
• Ensure adequate hydration
• Consider prophylactic anti-diarrheal agents

Common Pitfalls to Avoid

• Do not prematurely discontinue apremilast for mild-to-moderate GI symptoms in the first 2-4 weeks, as most resolve spontaneously 1, 3
• Do not confuse functional GI symptoms with gastritis—apremilast does not cause inflammatory gastric disease 1, 2
• Do not forget the mandatory 5-day titration schedule when initiating therapy, as this reduces GI symptoms 1, 2
• Do not ignore severe symptoms in elderly patients, as they may require hospitalization 2

Alternative Approach: Combination Therapy

If GI symptoms are intolerable but the patient is responding well to apremilast for their psoriasis/psoriatic arthritis, consider adding apremilast to a biologic agent rather than using it as monotherapy 5:

• Combination therapy with biologics is safe and may allow for better disease control 5
• In one study, only 2 of 22 patients developed diarrhea and 2 developed nausea when apremilast was added to biologics, with no discontinuations 5