What is the next step in managing a patient with moderate-to-severe psoriasis who cannot afford adalimumab (Humira)?

Next Step for Psoriasis When Adalimumab is Unaffordable

When a patient cannot afford adalimumab for moderate-to-severe psoriasis, initiate methotrexate as the first-line alternative systemic therapy, unless specific contraindications exist (hepatic disease, alcohol use, obesity with steatohepatitis), in which case phototherapy (narrowband UVB) should be the next step. 1

Primary Alternative: Methotrexate

• Methotrexate is the most commonly used systemic agent worldwide for moderate-to-severe psoriasis and represents the standard non-biologic option when biologics are unaffordable 1
• Dermatologists are well-trained in methotrexate use and typically employ dose strategies designed to maintain the minimal effective dose for each patient 1
• Methotrexate can be combined with topical corticosteroids and vitamin D analogues to enhance efficacy 1

Critical Contraindications to Methotrexate

Avoid methotrexate in patients with:

• Overweight/obesity with likely steatohepatitis (known risk factor for increased hepatotoxicity) 1
• Moderate-to-heavy alcohol intake (increases liver toxicity risk) 1
• Pre-existing liver disease or elevated liver enzymes 1
• Women of childbearing potential without reliable contraception (pregnancy category X) 1

Monitoring Requirements for Methotrexate

• Baseline: complete blood count, liver function tests, hepatitis B and C screening 1
• Ongoing: monitor for clinical response, side effects (nausea, fatigue), blood cell counts, and liver enzyme alterations 1

Secondary Alternative: Phototherapy

If methotrexate is contraindicated, narrowband UVB phototherapy is the next recommended step 1

• Phototherapy has fewer systemic toxicities compared to traditional systemic agents 1
• Particularly appropriate for patients with extensive prior phototherapy history, though cumulative UV exposure increases skin cancer risk when combined with immunosuppressants like cyclosporine 1

Third-Line Option: Cyclosporine (Short-Term Only)

Cyclosporine should be reserved as a "rescue" medication for severe flares, not as maintenance therapy 1

• FDA-approved for only up to 1 year of continuous therapy at a time 1
• Highly effective but limited by nephrotoxicity 1

Specific Contraindications to Cyclosporine

• Hypertension (cyclosporine has high probability of exacerbating blood pressure) 1
• Extensive prior UVB/PUVA treatment history (significantly increases risk of eruptive squamous cell carcinoma and basal cell carcinoma) 1
• Concurrent statin use (rosuvastatin and other statins metabolized by cytochrome P450 3A4 increase cyclosporine serum levels) 1
• Renal impairment or baseline elevated creatinine 1

Fourth-Line Option: Acitretin

• Acitretin is considered to have fewer significant safety issues compared to other traditional systemic agents 1
• Can be combined with phototherapy or topical therapies 1
• Pregnancy category X; requires contraception during and for 3 years after discontinuation in women of childbearing potential 1

Cost-Effectiveness Considerations

Among biologics, if patient assistance programs or biosimilars make any biologic accessible, adalimumab has the most favorable incremental cost-effectiveness ratio ($544/QALY) compared to etanercept, infliximab, efalizumab, and alefacept 2

• Explore manufacturer patient assistance programs for adalimumab before abandoning biologic therapy entirely 2
• Biosimilar adalimumab products may offer significant cost savings while maintaining efficacy 2

Critical Pitfalls to Avoid

• Never use systemic corticosteroids (prednisone) for psoriasis due to poor long-term efficacy and risk of severe rebound flares upon discontinuation 3
• Do not delay appropriate systemic therapy in patients with >5% body surface area involvement or PASI ≥10 with DLQI >10 3
• Avoid combining cyclosporine with extensive phototherapy history due to dramatically increased skin cancer risk 1
• Do not use methotrexate in patients with steatohepatitis, alcohol use, or without reliable contraception in women of childbearing age 1

Algorithm for Decision-Making

1. First, assess for methotrexate contraindications (liver disease, alcohol use, obesity with steatohepatitis, pregnancy risk) 1
2. If no contraindications exist: Start methotrexate with appropriate monitoring 1
3. If methotrexate contraindicated: Initiate narrowband UVB phototherapy 1
4. If phototherapy fails or is inaccessible: Consider short-term cyclosporine (≤1 year) if no hypertension, renal disease, or extensive UV history 1
5. Throughout: Aggressively pursue patient assistance programs or biosimilar options to access adalimumab 2