blocking drugs has been associated with rare cases of new onset or exacerbation of demyelinating diseases (e.g., multiple sclerosis, transverse myelitis, optic neuritis, seizure disorder), so these drugs should not be used to treat patients with a history of demyelinating disease. Infliximab may be associated with infusion reactions, which occur in approximately 3.8 percent of patients. Live viral vaccines should not be administered to patients receiving antiTNF-alpha drugs. The newest member of the biologic therapy group is ustekinumab (Stelera). It is a fully human monoclonal antibody against interleukins -12 and -23, key players in psoriasis. Interleukin -12 promotes the population of Th1 cells in psoriatic lesions, while interleukin -23 promotes the Th17 cell population. Ustekinumab’s clinical effect on plaque-type psoriasis is dramatic, with the majority of patients demonstrating marked improvement or complete clearance. Ustekinumab is administered subcutaneously and must
Studies show psoriasis severity to be related to compromised employment, income levels, self-esteem, and social withdrawal. be administered by a provider. Two injections are given 30 days apart and then every 12 weeks, for greater patient convenience (etanercept is given every week, adalimumab every two weeks, infliximab every six to eight weeks). Ustekinumab has been used for only three years, so its longterm safety is unknown. Side effects include possible increased risk of infection and a theoretical risk of malignancy. A rare neurological complication, posterior reversible encephalopathy syndrome, has been described in ustekinumab-treated patients and has been seen in patients treated with cyclosporine, tacrolimus, and interferon alpha. The relationship to ustekinumab is unclear, and longer experience will be necessary for clarification. Though
ustekinumab is not FDAapproved for therapy of psoriatic arthritis, in my experience it improves joint pain and stiffness in psoriatic patients. There have been several reports of increased risk of myocardial infarction with the use of ustekinumab. Interleukin -12 or -23 may have a protective effect against atheroma formation within blood vessels. Therefore, it may be prudent to screen possible candidates for ustekinumab for cardiovascular risk factors. Some clinicians advocate the use of low-dose aspirin in such patients. More experience will be needed before this risk can be accurately assessed.
Limited psoriasis often can be controlled with topical therapy. Moderate to severe psoriasis is much more challenging and has a 15 percent to 25 percent associated risk of inflammatory arthritis and a risk of major adverse cardiovascular events 2.5 times higher than the risk for the general population. Advances in therapy— narrow-band UVB, acitretin, and the biologic agents—have revolutionized patient management. The biologic agents have had a profound impact on management of psoriatic and rheumatoid arthritis. They may also have a major impact on the adverse cardiovascular events that afflict many of our psoriatic patients. Mitchell Bender, MD, practices with Dermatology Specialists PA and is an adjunct clinical faculty member in the Department of Dermatology at the University of Minnesota Medical School, Minneapolis.
A global health issue
Psoriasis is a major global health issue, thought to affect 125 million people worldwide.
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The Northwest Wisconsin Region of Mayo Clinic Health System has more than 300 physicians representing a wide range of medical specialties in a community healthcare setting. We are a respected and financially secure organization with strong emphasis on high quality care and patient satisfaction. A Mayo One emergency medical helicopter is based in Eau Claire, offering surrounding communities access to the area’s only verified Level II trauma center. Our current opportunities include: Dermatology Oncology Emergency Medicine Orthopedic Surgery – General, Sports, & Trauma Endocrinology Palliative Care Family Medicine Pathology General Surgery PM & R Hospitalist Psychiatry – Adult Internal Medicine Rheumatology Neurology Urology Neurosurgery If you wish to learn more or to express interest in this position, please contact: Cyndi Edwards/Christie Blink by phone (800-573-2580); email edwards.cyndi@mayo.edu or blink.christie@mayo.edu
FEBRUARY 2012
MINNESOTA PHYSICIAN
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