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Apremilast is FDA approved for treating psoriatic arthritis in adult patients with moderately to severely active disease, plaque psoriasis in adult patients who are candidates for phototherapy or systemic therapy, and adults with Behcet disease associated with oral ulcers. It is a small molecule phosphodiesterase 4 (PDE4) inhibitor. Apremilast is also used off-label for various dermatologic disorders that are unresponsive or ineffective to conventional therapy (systemic corticosteroids or immunosuppressive agents). This activity will highlight the mechanism of action, adverse event profile, and other key factors pertinent to interprofessional team members in managing patients with moderate to severe psoriatic arthritis unresponsive to first-line therapy, plaque psoriasis, and Behcet disease. Objectives: Identify the mechanism of action of apremilast. Describe the potential adverse effects of apremilast. Review the appropriate monitoring for patients receiving apremilast. Summarize interprofessional team strategies for improving care coordination and communication to advance apremilast use in treating psoriatic arthritis, plaque psoriasis, and Behcet disease and improve outcomes. Access free multiple choice questions on this topic.

Once consumed, the agent is metabolized hepatically by the cytochrome P450 (CYP) system, specifically the CYP3A4 enzyme, and possesses a terminal half-life of 6 to 9 hours. Although moderate to severe hepatic impairment do not require dosing adjustments, patients with underlying severe renal impairments characterized as CrCl less than 30 mL/min requires dosage adjustment. The agent is eliminated primarily by the kidneys and excreted in urine (58%) and feces (39%). Subjects with a CrCl greater than or equal to 30 mL/minute do not require dosing adjustments. The use of apremilast in sequence with potent CYP450 inducers (rifampin, phenytoin, phenobarbital) is not recommended as drug-drug reactions may occur further, causing alterations in drug plasma concentration. No clinically significant drug interactions were reported with CYP450 inhibitors (ketoconazole, methotrexate)e).[13]

Apremilast is classified as a small-molecule phosphodiesterase 4 (PDE4) inhibitor. It is indicated for psoriatic arthritis in adult patients with moderately to severely active disease, plaque psoriasis in adult patients that are candidates for phototherapy or systemic therapy, and adults with oral ulcers associated with Behcet's disease. Managing patients with such ailments necessitates interprofessional communication and continuity of care from the healthcare team. The interprofessional healthcare team should include a primary care physician (PCP), a rheumatologist, a dermatologist, a physical therapist (PT), nursing staff, and a pharmacist. Open-ended communication among patients and providers and thorough clinical analysis by the healthcare team can lead to more precise and practical treatment strategies leading to improved patient outcomes. [Level 5] Patients being initiated on therapy with apremilast should be counseled thoroughly on the 5-day titration regime and the potential risk of gastrointestinal adverse effects. Patients experiencing these effects should also be counseled that the effects can occur within the first 14 days of initiating therapy and typically resolve within 28 days. Patients who experience severe diarrhea, nausea, or vomiting should have dosing adjustments or discontinue their treatment. Patients who develop severe diarrhea should be assessed for complications such as volume depletion and hypotension and corrected promptly, particularly in elderly patients receiving apremilast. Patients should also be advised of potential neuropsychiatric adverse effects such as depression and suicidal ideation or behavior while receiving therapy. Patients with an underlying psychiatric history considering apremilast should be consulted with their psychiatrist to determine the patient's baseline psychiatric health and with the specialist to determine the benefits of therapy. Routine psychiatric assessments should be done before and after initiating treatment in such patient demographics. Patients should also be monitored by their prescribing clinician for regular weight checks and advised to report any significant weight decreases. In such an occurrence, dosing adjustments or treatment termination by the healthcare team should be prompted.

Patients should also be advised of potential neuropsychiatric adverse effects such as depression and suicidal ideation or behavior while receiving therapy. Patients with an underlying psychiatric history considering apremilast should be consulted with their psychiatrist to determine the patient's baseline psychiatric health and with the specialist to determine the benefits of therapy. Routine psychiatric assessments should be done before and after initiating treatment in such patient demographics. Patients should also be monitored by their prescribing clinician for regular weight checks and advised to report any significant weight decreases. In such an occurrence, dosing adjustments or treatment termination by the healthcare team should be prompted. The interprofessional team should also regularly review the latest guidelines on psoriatic arthritis, plaque psoriasis, and oral ulcers associated with Behcet disease. Patients with any known hypersensitivity to apremilast and its constituents are contraindicated for treatment. Apremilast is labeled as pregnancy category C. Women of reproductive potential should be advised about the potential risk of pregnancy loss with apremilast. They should be informed of pregnancy planning and prevention. Contraception should be considered prior to initiate apremilast treatment in childbearing females. Lactating and breastfeeding women should also be advised not to receive apremilast. The primary care physician should be aware of the patient's vaccination status, and all immunizations should be up to date before starting treatment. The patient should also be advised that receiving live vaccinations during treatment with apremilast is not recommended.

The interprofessional team should also regularly review the latest guidelines on psoriatic arthritis, plaque psoriasis, and oral ulcers associated with Behcet disease. Patients with any known hypersensitivity to apremilast and its constituents are contraindicated for treatment. Apremilast is labeled as pregnancy category C. Women of reproductive potential should be advised about the potential risk of pregnancy loss with apremilast. They should be informed of pregnancy planning and prevention. Contraception should be considered prior to initiate apremilast treatment in childbearing females. Lactating and breastfeeding women should also be advised not to receive apremilast. The primary care physician should be aware of the patient's vaccination status, and all immunizations should be up to date before starting treatment. The patient should also be advised that receiving live vaccinations during treatment with apremilast is not recommended. The interprofessional healthcare team should carefully monitor and routinely follow up with patients with severe renal impairment receiving apremilast. Patients with creatinine clearance of less than 30 mL/min should be thoroughly counseled and educated on dosing modifications and the risk of adverse events. In such patients, during the initial 5-day titration of therapy, subjects should be advised to miss their evening dosages and have their daily dosages decreased to 30mg once daily after that. The healthcare team should reconsider subjects who have not shown clinical improvements or therapeutic benefits over the 16-week period for discontinuation of apremilast. Continuous intercommunication between the PCP and specialists and their patients can help establish a therapeutic alliance when managed with apremilast promoting medication compliance, reducing adverse effects from apremilast, and improving disease outcomes.[2]