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Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease

Background: Psoriasis continues to have unmet needs in its management despite introduction of newer molecules. Monotherapy with these newer agents may not achieve therapeutic goals in all cases, hence necessitating their combinations with other molecules. Improved understanding of newer as well as c...

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Autores principales: Arora, Sandeep, Das, Pankaj, Arora, Gulhima
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416676/
https://www.ncbi.nlm.nih.gov/pubmed/34490293
http://dx.doi.org/10.3389/fmed.2021.696597
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author Arora, Sandeep
Das, Pankaj
Arora, Gulhima
author_facet Arora, Sandeep
Das, Pankaj
Arora, Gulhima
author_sort Arora, Sandeep
collection PubMed
description Background: Psoriasis continues to have unmet needs in its management despite introduction of newer molecules. Monotherapy with these newer agents may not achieve therapeutic goals in all cases, hence necessitating their combinations with other molecules. Improved understanding of newer as well as conventional treatment modalities and experiences in their combinations hence necessitates therapeutic guidelines for their use in psoriasis. Objective: To review the combinations of treatments reported in literature and recommendations for their use based on best current evidence in literature. Methods: A literature review of MEDLINE database for studies evaluating combinations of newer therapies with conventional therapies in psoriasis was done. Newer therapies were identified as biologic disease modifying anti rheumatic drugs and other molecules such as apremilast while conventional therapies included methotrexate, cyclosporine, or retinoids, phototherapy and others. The therapeutic guidelines are proposed with the aim to provide evidenced based approach to combine newer and conventional agents in day-to-day psoriasis management. Findings: Combination of acitretin and narrow band ultraviolet B (NB-UVB)/Psoralen with ultraviolet A (PUVA) achieves faster clearance and allows reduction of dose of the latter. A variable outcome is reported of methotrexate with TNF-α inhibitors vs. TNF-α inhibitors alone, although addition of methotrexate appears to reduce immunogenicity of TNF-α inhibitors thereby preventing formation of anti-drug antibodies especially in case of infliximab. While combination of acitretin and PUVA is beneficial, combining TNF-α inhibitors and phototherapy too produces better and faster results but long term risks of Non Melanoma Skin Cancers (NMSCs) may preclude their use together. Combination of cyclosporine and phototherapy is not recommended due to greater chances of NMSCs. Adding phototherapy to Fumaric Acid Esters (FAEs) improves efficacy. Apremilast can be safely combined with available biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. Hydroxyurea and acitretin may be used together increasing their efficacy and reducing doses of both and hence their adverse effects. Conclusion: Selected clinical scenarios shall benefit from combinations therapies, improving efficacy of both conventional and newer agents and at the same time helping reduce toxicity of higher dosages when used individually.
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spelling pubmed-84166762021-09-05 Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease Arora, Sandeep Das, Pankaj Arora, Gulhima Front Med (Lausanne) Medicine Background: Psoriasis continues to have unmet needs in its management despite introduction of newer molecules. Monotherapy with these newer agents may not achieve therapeutic goals in all cases, hence necessitating their combinations with other molecules. Improved understanding of newer as well as conventional treatment modalities and experiences in their combinations hence necessitates therapeutic guidelines for their use in psoriasis. Objective: To review the combinations of treatments reported in literature and recommendations for their use based on best current evidence in literature. Methods: A literature review of MEDLINE database for studies evaluating combinations of newer therapies with conventional therapies in psoriasis was done. Newer therapies were identified as biologic disease modifying anti rheumatic drugs and other molecules such as apremilast while conventional therapies included methotrexate, cyclosporine, or retinoids, phototherapy and others. The therapeutic guidelines are proposed with the aim to provide evidenced based approach to combine newer and conventional agents in day-to-day psoriasis management. Findings: Combination of acitretin and narrow band ultraviolet B (NB-UVB)/Psoralen with ultraviolet A (PUVA) achieves faster clearance and allows reduction of dose of the latter. A variable outcome is reported of methotrexate with TNF-α inhibitors vs. TNF-α inhibitors alone, although addition of methotrexate appears to reduce immunogenicity of TNF-α inhibitors thereby preventing formation of anti-drug antibodies especially in case of infliximab. While combination of acitretin and PUVA is beneficial, combining TNF-α inhibitors and phototherapy too produces better and faster results but long term risks of Non Melanoma Skin Cancers (NMSCs) may preclude their use together. Combination of cyclosporine and phototherapy is not recommended due to greater chances of NMSCs. Adding phototherapy to Fumaric Acid Esters (FAEs) improves efficacy. Apremilast can be safely combined with available biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. Hydroxyurea and acitretin may be used together increasing their efficacy and reducing doses of both and hence their adverse effects. Conclusion: Selected clinical scenarios shall benefit from combinations therapies, improving efficacy of both conventional and newer agents and at the same time helping reduce toxicity of higher dosages when used individually. Frontiers Media S.A. 2021-08-19 /pmc/articles/PMC8416676/ /pubmed/34490293 http://dx.doi.org/10.3389/fmed.2021.696597 Text en Copyright © 2021 Arora, Das and Arora. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Medicine
Arora, Sandeep
Das, Pankaj
Arora, Gulhima
Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease
title Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease
title_full Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease
title_fullStr Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease
title_full_unstemmed Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease
title_short Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease
title_sort systematic review and recommendations to combine newer therapies with conventional therapy in psoriatic disease
topic Medicine
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416676/
https://www.ncbi.nlm.nih.gov/pubmed/34490293
http://dx.doi.org/10.3389/fmed.2021.696597
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