TABLE 2.

Overview of systemic agents for the treatment of chronic plaque psoriasis, oral systemic agents17,43-45,52-61

DRUG FACTORS	METHOTREXATE	CYCLOSPORINE	ACITRETIN	APREMILAST
Contraindications	Pregnancy Breast-feeding Alcoholism/abuse Chronic liver disease or excessive alcohol use Immune deficiency syndromes Blood dyscrasias (anemia, thrombocytopenia, leukopenia, bone marrow hypoplasia) Known hypersensitivity to methotrexate	Abnormal renal function Uncontrolled hypertension Malignancy Hypersensitivity to cyclosporine	Pregnancy or intention to become pregnant ≤3 years after discontinuation Ethanol consumption (women) for 2months after discontinuation Blood donation within 3 years after discontinuation Severely impaired liver or kidney function Hypersensitivity to acitretin or other retinoids	Hypersensitivity to apremilast
Baseline testing	Physical exam and history: alcohol intake, exposure to hepatitis B and C, family history of liver disease Screen for latent TB infection CBC with differential and platelet count Hepatic enzymes Renal function tests Chest radiograph, liver biopsy, HIV, pregnancy tests in selected high-risk patients	History: possible exposure to TB, hepatitis Bor C, family history of renal disease Screen for latent TB Physical exam: document blood pressure, evaluate for presence of infection, tumors Serum creatinine on 2 separate occasions Other clinical laboratory tests: BUN, urinalysis, CBC, magnesium, potassium, uric acid, lipids, liver enzymes, bilirubin Evaluate nephrotoxicity risk; obesity, age, diabetes Ensure contraception	Two separate negative pregnancy tests before initiating treatment Laboratory testing includes lipid profile, LFTs, and renal function tests	Physical exam and history: depression No laboratory pre-screening is needed In patients with renal disease, determine creatinine clearance >30mL/minute
Ongoing monitoring	Monthly: hematology Bimonthly: hepatic and renal function tests; pulmonary function tests, if clinical signs warrant	Every other week for first 3 months, then monthly thereafter: BP, BUN, creatinine, CBC, LFTs, lipids, magnesium, potassium, uric acid Pregnancy tests	Monthly negative pregnancy test before receiving prescription for drug Every other week for first eight weeks, then every 6–12 weeks thereafter: lipid profile and LFTs Every three months: CBC and renal function Closely monitor blood sugar levels in diabetic patients	Periodic physical exam Monitor body weight Be alert for depression, suicidal thoughts or changes in mood No ongoing clinical laboratory monitoring is needed
Patient education	Avoid excessive alcohol intake Avoid use of PPIs Consistent use of highly effective birth control methods Pregnancy Category X	Must not drink grapefruit juice Avoid live vaccinations Avoid NSAID use No excessive alcohol use Do not breast-feed Pregnancy Category C	Lifestyle/diet changes to manage potential hyperlipidemia Caution when operating vehicle at night Avoid sun lamps, high-dose vitamin A supplements Pregnancy Category X Do not use in women who intend to become pregnant within three years; following treatment discontinuation women must not become pregnant for at least 3 years	No lifestyle changes are needed Pregnancy Category C
Dosing schedule	7.5–30mg, weekly, given in divided doses every 12 hours Should not exceed 30mg/week Folate (1–5mg/d except the day of methotrexate) can betaken daily while receiving methotrexate	1.25–2.0mg/kg twice daily oral dose Should not exceed 4.0 mg/kg/day Do not use continuously >1 year Best used as interventional treatment or part of an alternating/rotating therapy plan	10–50mg/day, single oral dose with the main meal ≤25mg/day may minimize side effects	5-day oral dose titration during Week 1 30mg BID thereafter In patients with severe renal impairment (creatinine clearance <30mL/minute), 30mg once daily
Drug interactions	PPIs, salicylates, NSAIDs, phenylbutazone, Phenytoin, sulfonamides, probenecid, cisplatin, mercaptopurine, oral antibiotics, other potential hepatotoxins, theophylline	Antibiotics, NSAIDs, melphalan, amphotericin B, antifungals, calcium channel blockers, Cimetidine, ranitidine, tacrolimus, fibric acid derivatives, methotrexate, methylprednisone, allopurinol, amiodarone, bromocriptine, colchicine, anticonvulsants, bosentan, octreotide, orlistat, sulfinpyrazone, terbinafine, ticlopidine, St. John’s Wort, SSRIs, boceprevir, telaprevir	Methotrexate, phenytoin, tetracyclines, oral retinoids, vitamin A supplements, microdose progestin minipill	Strong CYP450 inducers: rifampin, phenobarbital, carbamazepine, phenytoin
NSAID: Nonsteroidal anti-inflammatory drug; PPI: Proton pump inhibitor; CYP450: Cytochrome P450; CBC: Complete blood count; BP: Blood pressure; BUN: Blood urea nitrogen; TB: Tuberculosis; BID: Twice daily; LFT: Liver function test