Table 1.

Expert-Validated Questionnaire and Summary of Responses

Sr. No	Questions	Response
1	Do you use apremilast as monotherapy or combination therapy?	Although 77% of the dermatologists use apremilast as monotherapy and combination therapy, most commonly, apremilast is prescribed along with other drugs as combination therapy
2	In which severity grade of plaque psoriasis (as measured by PGA) do you prescribe apremilast therapy?	85% response was received for moderate psoriasis with BSA involvement <10%
3	In psoriasis, do you consider apremilast as a first-line drug or second-line drug?	40% prescribe apremilast as a first-line drug, whereas 60% prescribe it as a second-line drug in the management of psoriasis, hence no consensus achieved
4	In which type of psoriasis other than plaque-type do you prescribe apremilast?	About 97% responded that they use apremilast in scalp, palmoplantar, and nail psoriasis, of which 35% prescribe it as the first-line and 65% as the second-line drug
5	After starting apremilast, how long on an average does it take for your patients to show clinical improvement (eg, PASI 50/equivalent fall in BSA or PGA) in patients with psoriasis?	89% responded that it takes about 4–6 weeks for apremilast to show clinical improvement
6	Once patients achieve disease clearance with apremilast, is it recommended to stop the apremilast therapy?	71% respondents feel that apremilast should not be stopped abruptly after achieving disease clearance
7	What is your preferred dose of apremilast in the maintenance phase?	No consensus achieved; 39% mentioned that the maintenance dose of apremilast varies from patient to patient, 27% preferred apremilast 30 mg twice a day, whereas 21% preferred 30 mg once a day
8	What is the percentage of your patients who achieve complete remission with apremilast?	87% of the respondents commented that they achieve complete remission in less than 50% of their patients
9	What is your general opinion regarding the predictability of clinical response to apremilast?	In 92% of the responses, predictability of apremilast is low to moderate, ie, in some of the patients it works well, whereas in some of the patients it does not show a satisfactory response
10	Do you prescribe apremilast with other systemic agents?	90% of the dermatologists combine apremilast with other systemic agents. Among all systemic agents, apremilast is commonly combined with methotrexate
11	Can apremilast be used as switchover therapy in patients who have achieved disease clearance with other systemic drugs?	93% responded positively for apremilast as switchover therapy, and in such cases, the previous systemic drug should be withdrawn gradually over time
12	Apremilast with biologics?	In India, only 29% of the dermatologists use biologics in the management of psoriasis. Of these, 65% combine biologics with apremilast to maintain the remission and reduce the cost of therapy, thus improving the patient outcome
13	Can apremilast be considered as a preferred drug compared to other immunosuppressive drugs in the current scenario of global COVID pandemic?	85% positive responses were received
14	Can apremilast be prescribed in patients with high risk of developing TB infection?	77% commented that apremilast can be used in patients with high risk of developing TB infection
15	Can apremilast be prescribed in HIV patients for the management of psoriasis?	A positive response was received from 79% of the respondents
16	Can apremilast be prescribed in patients with hepatitis B or hepatitis C?	67% voted that apremilast can be used in such patients
17	Since apremilast is associated with significant weight loss up to 10%, should it be stopped if >10% weight loss is experienced in patients with psoriasis?	Apremilast should be stopped in these cases, according to 72% of the dermatologists
18	Can apremilast be considered as a preferred drug in female patients in the reproductive age group trying to conceive?	No consensus achieved; 50% responded positively whereas 18% opted for the “do not know” option
19	Can apremilast be prescribed in patients with psychiatric disorders like depression?	60% responded as not to be used, whereas 40% responded that it can be used
20	Can apremilast be considered as a safe drug in the management of patients with psoriasis with other comorbid conditions like cardiac diseases, diabetes, or hypertension?	As per 91% of responses, apremilast is one of the safest drugs in comorbid conditions like cardiac disease and diabetes
21	Drug–drug interactions can be very crucial and can have a significant effect on patient outcomes, especially in patients who are on polypharmacy. Can it be considered as safe drug in such patients?	80% responded positively
22	Can apremilast be prescribed in paediatric patients with psoriasis?	45% voted negatively, whereas for 55%, it can be used and the dosage varies from patient to patient
23	Do you routinely do laboratory monitoring in psoriasis patients on apremilast?	No consensus achieved; 55% no, 45% yes
24	Can apremilast be considered as cost-effective therapy over a long period of time compared to other conventional medications?	83% considered apremilast as a cost-effective option over other conventional drugs
25	In how many patients are side effects seen with apremilast in your clinical practice?	About 40% of patients receiving apremilast experience side effects, most of them in the initial period, with 30 mg twice daily. Diarrhea, vomiting, and headache are at the top of the list
26	What is the most common titration method that you use in your clinical practice?	Although 62% of the dermatologists use a starter pack as recommended, there are many different titration methods available in real-world practice
27	According to you, can apremilast 20 mg twice daily be useful in those patients who are not tolerating 30 mg twice daily regimen?	79% were in agreement with this
28	Can apremilast be used in off-label indications?	Atopic dermatitis 79%, lichen planus 74%, alopecia areata 65%, and vitiligo 47%

Abbreviations: PGA, physician global assessment; BSA, body surface area; PASI, Psoriasis Area and Severity Index.