a patient with eruptive psoriasis need to start biologic treatment but have an increased liver enzymes X3 of the normal value, what treatment would you suggest ? I am looking for new Articles providing the latest therapy.
@Farzaneh Sadeghi - Apremilast may be a good option. This is one review article on the same: 10.4103/idoj.IDOJ_437_18
- First of all assess for the cause of transaminitis; was the patient on Mtx at any point and when was the last dose taken? Repeat transaminase level, rule out viral hepatitis, take a drug history to look for hepatotoxic drugs, abdominal ultrasound if you're suspecting NASH etc.
- Assess the severity (extent and disability) of the psoriasis
If not severe (Limited plaque psoriasis i.e. < 20% BSA or PASI20% BSA or PASI>10), some of the systemic/other agents which (according the literature) are not hepatotoxic are:
- Narrow band UVB: slower onset of action; good for long term maintenance
- Cyclosporine: quick onset of action, good for quick induction of remission
- Apremilast: hepatic impairment does not alter its pharmacokinetics hence no dose adjustmest is required (1) and no pre-treatment tests are required (2). It is indicated when other systemic agents are contraindicated (2).
Feel free to add inputs if anything important was missed.
(1) Zerilli T, Ocheretyaner E. Apremilast (Otezla): A New Oral Treatment for Adults With Psoriasis and Psoriatic Arthritis. P T. 2015;40(8):495-500
(2) Vujic I, Herman R, Sanlorenzo M, et al. Apremilast in psoriasis - a prospective real-world study. J Eur Acad Dermatol Venereol. 2018;32(2):254-259. doi:10.1111/jdv.14598
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