How should I initiate Otezla (apremilast) in an 83‑year‑old patient with psoriatic arthritis who has normal renal and hepatic function?

How to Initiate Otezla (Apremilast) in an 83-Year-Old Patient with Psoriatic Arthritis

Start apremilast using the standard 5-day titration schedule (10 mg AM on Day 1, progressing to 30 mg twice daily by Day 6), with heightened monitoring for diarrhea, nausea, and vomiting given the patient's age. 1

Standard Dosing Titration

Follow the FDA-approved titration schedule to minimize gastrointestinal side effects: 1

• Day 1: 10 mg in the morning only
• Day 2: 10 mg morning, 10 mg evening
• Day 3: 10 mg morning, 20 mg evening
• Day 4: 20 mg morning, 20 mg evening
• Day 5: 20 mg morning, 30 mg evening
• Day 6 and thereafter: 30 mg twice daily (maintenance dose) 1

Tablets should be swallowed whole without crushing, splitting, or chewing, and can be taken without regard to meals. 1

Critical Age-Related Monitoring

Patients 65 years and older are at higher risk for complications from severe gastrointestinal side effects. 1 Your 83-year-old patient requires:

• Close monitoring during the first 2-4 weeks when diarrhea, nausea, and vomiting most commonly occur 1, 2
• Weekly check-ins (phone or in-person) during the first month to assess for severe GI symptoms 1
• Immediate evaluation if severe diarrhea or vomiting develops, as elderly patients are more susceptible to volume depletion and hypotension complications 1

Renal Function Considerations

Despite good kidney function, verify the creatinine clearance is ≥30 mL/min. 1 If CLcr is:

• ≥30 mL/min: Use standard dosing as outlined above 1
• <30 mL/min: Reduce to 30 mg once daily and use only the AM titration schedule (skip all PM doses) 1

Pre-Treatment Screening

Screen for depression and suicidal ideation before initiating therapy. 1 Apremilast is associated with increased depression risk, and careful risk-benefit assessment is required in patients with psychiatric history. 1

Assess for hypersensitivity to apremilast or excipients, as this is an absolute contraindication. 1

Monitoring During Treatment

Weight monitoring at each visit is essential: 3

• If weight loss exceeds 5% from baseline, consider discontinuing apremilast 3

Depression screening at each visit: 3

• Depression occurs in approximately 1% of patients 3
• Monitor for mood changes, particularly in the first few months 1

No routine laboratory monitoring is required — a key advantage of apremilast over other systemic therapies. 3, 4

Managing Gastrointestinal Side Effects

If severe diarrhea, nausea, or vomiting develops: 1

• Consider dose reduction or temporary suspension 1
• Most patients improve quickly with dose adjustment 1
• Ensure adequate hydration, especially critical in elderly patients 1
• While most GI symptoms resolve within 4 weeks without intervention 2, chronic diarrhea requiring discontinuation has been reported 2

Clinical Context for This Patient

The 2018 ACR/NPF guidelines support apremilast as a reasonable option when: 5

• The patient prefers oral therapy over injections 5
• There are contraindications to TNF inhibitors (recurrent infections, congestive heart failure, demyelinating disease) 5
• The patient has cardiovascular disease, peptic ulcer disease, or renal impairment that contraindicates NSAIDs 5

However, note that TNF inhibitors remain the preferred first-line therapy for psoriatic arthritis due to superior efficacy. 6 Apremilast is a conditional recommendation based on very-low-quality evidence. 5

Common Pitfalls to Avoid

• Skipping the titration schedule: This significantly increases GI side effects 1
• Inadequate monitoring in elderly patients: Age ≥65 years increases risk of serious complications from GI symptoms 1
• Failing to screen for depression: Missing psychiatric contraindications can lead to serious adverse outcomes 1
• Not counseling about expected timeline: Efficacy may be seen as early as week 2, but full response takes longer 4