1. 1. Welcome to Hyatt Regency Bethesda Saturday, June 27, 2015 www.psoriasis.org Triggers, Treatments & You
2. 2. This activity is supported by an educational donation provided by: www.psoriasis.org The National Psoriasis Foundation is solely responsible for all content and development of this program. AbbVie, Inc. Amgen, Inc. Celgene Corporation Janssen BioTech, Inc. Novartis Pharmaceuticals, Inc.
3. 3. Reminders www.psoriasis.org Cell phones Restrooms Questions Evaluation form
4. 4. Our mission: to drive efforts to cure psoriatic disease and improve the lives of those affected Improve access to care Expand knowledge of psoriatic diseaseNationalPsoriasisFoundation 2015: $1.6 million Increase research www.psoriasis.org
5. 5. Psoriatic Arthritis (PsA) Project www.psoriasis.org Largest, most comprehensive realignment and expansion of its psoriatic arthritis program since the Foundation began Goals include: Reduce the average time of diagnosis Improve PsA outcomes for people with the disease Expand the PsA research community
6. 6. Advocacy and Government Relations Priorities Learn more at: psoriasis.org/advocacy Promote federal research efforts and ensure individuals living with psoriatic diseases have fair and affordable access to needed treatments. The 2015 advocacy agenda priorities: Growing the federal investment in psoriatic disease research Building on the psoriasis and psoriatic arthritis public health efforts at the CDC Reducing treatment barriers (including cost) Ensuring affordable access to new treatments
7. 7. Join us Team NPF Walk Washington, D.C. occurs Sunday, September 27th at Lincoln Memorial Reflecting Pool www.psoriasis.org Visit: www.teamnpf.org/DCwalk
8. 8. Join us Team NPF Cycle Inaugural Ride Saturday, August 15, 2015 Unionville Vineyards, Ringoes, NJ www.psoriasis.org For more information contact: Robert Grabel at rgrabel@psoriasis.org
9. 9. What You Will Learn Today About common psoriasis and psoriatic arthritis triggers The latest research to help reduce itch, pain and swelling Treatment strategies and how to determine the best options for you www.psoriasis.org
10. 10. Triggers, Treatments & You Ronald Prussick, M.D., F.R.C.P.C., F.A.A.D. www.psoriasis.org Medical Director, Washington Dermatology Center Rockville and Frederick, MD Assistant Clinical Professor of Dermatology George Washington University Washington, D.C.
11. 11. Disclosures Dr. Prussick www.psoriasis.org The National Psoriasis Foundation is solely responsible for all content and development of this program. I have the following financial relationships to disclose: Consultant: Immunotec, Inc., Medimetriks Pharmaceuticals, Inc. Speakers Bureau: AbbVie, Inc., Celgene Corporation, Janssen Biotech, LOreal/Galderma Laboratories, L.P. Volunteer Member: Medical Board, National Psoriasis Foundation
12. 12. Psoriatic Disease: What We Know www.psoriasis.org Chronic, inflammatory disease of the skin and/or joints Causes rapid turnover of skin cells (10 times faster than normal) Periods of intense flares of the disease causing pain and itch May cause persistent warmth and swelling (inflammation) around a joint Related inflammation is associated with other health conditions
13. 13. Why does psoriatic disease occur? www.psoriasis.org Reason not entirely known Known players: Dendritic cells Mast cells TNF-alpha proteins Interleukin (IL) 17 Interleukin (IL) 12/23 Current model of psoriasis pathogenesis Journal of the American Academy of Dermatology http://www.jaad.org/article/S0190-9622(14)01001-9/pdf
14. 14. Current Research: Why You Flare www.psoriasis.org Dendritic cells (DCs) are a type of immune cell that play a role in psoriatic disease One kind of DCs, Plasmacytoid dendritic cells might trigger new psoriasis flares Plasmacytoid DCs are increased in psoriatic skin A different kind of DC, Langerhan cells are decreased in psoriatic skin. This decrease allows pro-inflammatory cytokines to increase
15. 15. Current Research: Why You Itch www.psoriasis.org Itch is present in between 70 and 90 percent of people with psoriasis Itch is associated with receptors that send a signal through fibers in the skin to your spinal cord and to the brain Identified itch receptors include: NGF (Nerve growth factor) TrkA (Tyrosine protein kinase) TRPV1 (Transient receptor potential vaniliod 1)
16. 16. Triggers of psoriatic disease www.psoriasis.org
17. 17. Psoriasis Triggers www.psoriasis.org Medications: Lithium Inderal, ACE inhibitors, beta-blockers Antimalarials Acute withdrawal of systemic or potent corticosteroids Prednisone
18. 18. Psoriasis Triggers www.psoriasis.org Infections: Strep throat Respiratory infections Staph Thrush (yeast infection in the mouth) Yeast Earache AlexanderRaths,123RFStockPhoto
19. 19. Triggers: What You Can Do www.psoriasis.org Medications: If you suspect a medication is irritating your skin, talk with your provider about other treatment options Infections: Obtain treatment for the infection to help calm or keep your psoriasis in control
20. 20. Psoriasis Triggers www.psoriasis.org Injury to the skin (Koebner Response): Cuts, scrapes, scratches Poison ivy or poison oak Bruises Sunburns Bug bites Tattoos Vaccinations or acupuncture Constant pressure and rubbing Injury -> inflammation and psoriatic arthritis
21. 21. Triggers: What You Can Do www.psoriasis.org Injury to the skin: Be careful when you know your psoriasis is active Treat injuries quickly. Dont pick or scratch bites or scabs Use sunscreen Talk with your provider prior to receiving a vaccine
22. 22. Psoriasis Triggers www.psoriasis.org Alcohol Smoking Hormones Psoriasis severity fluctuates with hormonal changes May improve during pregnancy but become worse after pregnancy Frequency peaks during puberty and menopause ArveBellum,123RFStockPhoto
23. 23. Triggers: What You Can Do www.psoriasis.org Stop or limit use of alcohol Stop smoking Hormonal changes may mean talk with your provider about changing your psoriasis treatment options IvanMateev,123RFStockPhoto
24. 24. Psoriasis and Psoriatic Arthritis Triggers www.psoriasis.org Stress Cause onset or aggravate psoriasis symptoms Itch Pain Weather Cold, dry weather causing dry skin and inflammation
25. 25. Triggers: What You Can Do www.psoriasis.org Stress Try meditating, mindfulness therapy or Tai Chi to relax Spa therapy Connect with others who understand Weather Stay warm, place heating pads over painful joints, wear gloves Try non-weight-bearing exercises to improve joint function CathyYeulet,123RFStockPhoto
26. 26. Lifestyle Changes: What You Can Do www.psoriasis.org Eat a balanced diet and watch your weight Helps decrease your risk of serious health conditions Losing weight reduces pressure on joints Eat plenty of fruits, vegetables, whole grains and fiber Decrease amounts of processed or refined carbohydrates Choose foods low in added sugar Be active with at least 30 minutes of moderate exercise, five times a week
27. 27. Treat Your Psoriasis and Psoriatic Arthritis www.psoriasis.org
28. 28. Purpose of treatment www.psoriasis.org Alleviate symptoms Reduce inflammation Reduce risk of psoriatic arthritis and other health conditions Slow progression of psoriatic disease Help improve self image Decrease commorbidities TracyHebden,123RFStockPhoto
29. 29. Factors that impact treatment choices www.psoriasis.org Disease severity in relation to: Body surface area Psoriasis area and severity index (PASI) Duration Quality of life Treatment is considered effective if achieving PASI reduction of 75 percent or more
30. 30. Assessing Severity of Psoriasis www.psoriasis.org
31. 31. Factors that impact treatment choices www.psoriasis.org Prior treatments Potential side effects Individual preferences and treatment strategies Joint involvement (i.e. psoriatic arthritis) Access to treatment, cost and insurance coverage If needed - financial assistance programs, discount cards, co-pay assistance programs are available to help For resources: www.psoriasis.org/financial-assistance
32. 32. Factors that impact treatment choices www.psoriasis.org Other health risks: Cardiovascular disease Metabolic syndrome (i.e. diabetes, high blood pressure, high cholesterol) Family history of cancer/lymphoma History of liver disease, tuberculosis Atherosclerosis
33. 33. Ultimately treatment choices www.psoriasis.org Are individualized What works for you may not work for another What used to work stops and a change may be needed Take time to work Need consistency with use and follow-up with a provider Reduce inflammation and symptoms
34. 34. 10:45 a.m. Snack break 11:00 a.m. Your Treatment Options www.psoriasis.org
35. 35. Your treatment options www.psoriasis.org Topicals Light therapy Oral Biologics PDE4 Biosimilars Alternative choices ChristineLanger-Pueschel,123RFStockPhoto
36. 36. www.psoriasis.org Topicals: What they do Slow growth of skin cells Flatten lesions Remove scale Reduce itch and inflammation
37. 37. www.psoriasis.org Over-the-counter topicals Options include products with: Salicylic acid (keratolytic or peeling agent) Coal tar Moisturizers or emollients -Lotions and creams (lightest) (shea butter, aloe vera, glycerin, lanolin, beeswax, colloidal oatmeal -Ointments (thickest) -Oils (more effective but messy)
38. 38. www.psoriasis.org Prescription Topicals Vitamin D Derivatives Dovonex, Calcitrene (calcipotriene) Vectical (calcitriol) Taclonex (calcipotriene and betamethasone dipropionate) Vitamin A Derivatives Tazorac (tazarotene)
39. 39. www.psoriasis.org Corticosteroids Anti-inflammatory agents that reduce itch, swelling and redness of lesions Topical steroid medications bind to steroid receptors in the skin and immune cells Over 80 different formulations Available in various strengths from least potent (class 7) to super potent (class 1)
40. 40. www.psoriasis.org Topical Steroids: Side effects and precautions Possible side effects: Thinning of the skin Changes in pigmentation Easy bruising Stretch marks Redness and dilated surface blood vessels Precautions: Systemic absorption Tachyphylaxis If pregnant or nursing Use in children Do not use strong steroids on the face or genitals Avoid applying on healthy skin Dont discontinue use abruptly
41. 41. www.psoriasis.org Occlusion Covering a topical to increase effectiveness and absorbency into the skin Topical is applied to the skin and then covered with impermeable materials such as plastic wrap, cellophane, waterproof dressing, or a nylon suit Check with your provider before occluding a topical
42. 42. www.psoriasis.org Using multiple topical treatments Make sure your health care provider clarifies the order you should apply your topicals (including moisturizer) Give each topical enough time to absorb before applying the next layer
43. 43. www.psoriasis.org Upcoming Treatments: Topicals Aerosal Foam (LEO 90100) Calcipotriol plus Betamethasone Dipropionate Once daily for treatment of plaque psoriasis Submitted for FDA approval Current research for youth Taclonex Scalp Topical Suspension for ages 12-17 (LEO 80185 Phase II trials) Calcipotriene Foam (Sorilux) for mild to moderate psoriasis use in ages 2 11 (GlaxoSmithKline STF 115469 Phase III)
44. 44. www.psoriasis.org Light Therapy Penetrates the skin to slow growth of skin cells Involves exposing the skin to a light source Consistency key
45. 45. www.psoriasis.org Light Therapy Light therapy is a good choice for: Children and adults Individuals who: Have thin plaques (minimal scale buildup) or guttate psoriasis Plaques occur in areas that are easy to expose Are responsive to natural sunlight Combination therapy
46. 46. www.psoriasis.org Source: Sunlight Natural sunlight UVA and UVB Short, multiple exposures Be cautious with tanning beds LjupcoSmokovski,123RFStockPhoto
47. 47. www.psoriasis.org Source: Ultraviolet light B (UVB) Options: Broad-band Narrow-band Clinic or home use Targeted treatment used when less than 5-10 percent of body surface is covered Whole-body treatment used when more than 5 percent of body surface area is covered
48. 48. www.psoriasis.org Source: PUVA Administered in a providers office Ultraviolet A used with the light-sensitizing medication psoralen (oral or applied to skin) Recommended for adults with: Moderate-to-severe psoriasis Stable plaque psoriasis Guttate psoriasis Psoriasis of the palms and soles Timing is critical
49. 49. www.psoriasis.org Source: Excimer (Xtrac) laser High-intensity beam of ultraviolet light administered in a clinic Targets select areas of skin Used to treat mild-to- moderate plaque psoriasis
50. 50. www.psoriasis.org Risks Associated with Light Therapy Risks include: Sunburn Skin cancer (www.aad.org) Premature aging Cataracts (PUVA) if eyes are not protected (controversial) Tell your provider what medications, treatments and dietary supplements you take
51. 51. www.psoriasis.org Systemics: What they do Work throughout the body to: Most agents suppress the hyperactive immune system Decrease activity of certain immune cells to slow the growth of skin cells Reduce inflammation
52. 52. www.psoriasis.org Methotrexate Take once a week Used to treat severe psoriasis and psoriatic arthritis See improvement in three to six weeks. May take six months for complete clearance Use folic acid to decrease side effects Sometimes used to rotate with other treatments Can be used with biologics to prevent resistance and increase response
53. 53. www.psoriasis.org Cyclosporine Take daily Take consistently Use to treat psoriasis Use no longer than one year (according to FDA preference). International Guidelines allow continuous, uninterrupted use for two years at a time. Avoid grapefruit, potassium-rich diet, St. Johns Wort, certain medications interact Protect your skin while in the sun OK to use with topical corticosteroids, vitamin D treatments
54. 54. www.psoriasis.org Soriatane Oral retinoid Take once a day with food Psoriasis may worsen before clearing After eight to 16 weeks of treatment, skin lesions improve. May take six months to reach peak effect. Works slowly for plaque psoriasis Used to treat severe psoriasis Rarely clears psoriasis alone Works best with phototherapy Dont donate blood
55. 55. www.psoriasis.org Risks Associated with Systemics Risks include: Liver disease Kidney function High blood pressure Lymphoma Precautions: Preconception and pregnancy Alcohol use
56. 56. www.psoriasis.org Biologics: What they do Target and block specific immune cells and proteins key to the development of psoriasis and psoriatic arthritis Reduce inflammation Inhibit joint damage in psoriatic arthritis SergeyNivens,123RFStockPhoto
57. 57. www.psoriasis.org What are Biologics? Protein-based drugs derived from living cells grown in a culture Action of biologics mimic the natural function of the body Taken by injection or IV infusion
58. 58. Why does psoriatic disease occur? www.psoriasis.org Reason not entirely known Known players: Dendritic cells Mast cells TNF-alpha proteins Interleukin (IL) 17 Interleukin (IL) 12/23 Current model of psoriasis pathogenesis Journal of the American Academy of Dermatology http://www.jaad.org/article/S0190-9622(14)01001-9/pdf
59. 59. www.psoriasis.org TNF-alpha Blockers Biologic blocks Block TNF-alpha production Treatment options include: -Enbrel (Etanercept) - Amgen -Humira (Adalimumab) - AbbVie -Remicade (Infliximab) - Janssen -Simponi (Golimumab) - Janssen -Cimzia (Certolizumab) - UCB
60. 60. www.psoriasis.org Interleukin 12/23 Inhibitor Binds to p40 protein found in IL-12 and IL-23 to inhibit inflammation that triggers psoriasis and psoriatic arthritis Current treatment: Stelara (Ustekinumab) - Janssen
61. 61. www.psoriasis.org New: Interleukin 17-A Inhibitor Binds to protein IL-17A to inhibit inflammation and immune responses that trigger psoriasis Current treatment: Cosentyx (Secukinumab) - Novartis -Prescribed for moderate to severe plaque psoriasis -Given by injection at week 0, 1, 2, 3, 4 and then every 4 weeks Inhibitor blocks
62. 62. www.psoriasis.org Upcoming IL-17 Inhibitor Ixekizumab (ILY2439821) Eli Lilly Monoclonal antibody against IL-17A protein cells Treatment of psoriasis and psoriatic arthritis Phase III trials
63. 63. www.psoriasis.org Upcoming IL-23 Inhibitors Guselkumab (CNTO1959) Janssen Monoclonal antibody to IL-23 Treatment of psoriasis Phase III trials Tidrakizumab (MK-322) - Merck Monoclonal antibody to IL-23 Treatment of psoriasis Phase III trials
64. 64. www.psoriasis.org Risks Associated with Biologics Common side effects: Respiratory infections Flu-like symptoms Injection site reactions Headache Rare side effects: Nervous system disorders Blood disorders Certain types of cancer Cautions: Pregnancy Compromised immune system Congestive heart failure Surgery
65. 65. www.psoriasis.org Phosphodiesterase-4 Inhibitor Inhibits enzyme phosphodiesterase-4 (PDE4) which controls most of the inflammatory action found in immune cells Current treatment: Otezla (Apremilast) - Celgene -Prescribed for psoriasis and psoriatic arthritis -Oral agent available as a 30mg tablet -Take continuously
66. 66. www.psoriasis.org Upcoming Oral Agents Tofacitinib (CP-690,550) Pfizer Baricitinib (Ly3009104/INCB280501)-Eli Lilly JAK (Janus Kinase) Inhibitors Reduces production of pro-inflammatory cells Treatment of psoriasis and/or psoriatic arthritis Phase III trials Adenosine CF101 (Can-Fite BioPharma) A3 Receptor inhibitor for treatment of psoriasis Phase III trials
67. 67. www.psoriasis.org Biosimilars Biosimilars are not chemically identical to biologics Offer potentially affordable treatments NPF biosimilar recommendations: FDA designates biosimilars are interchangeable with prescribed biologics Have unique nonproprietary names Notification of substitution is made
68. 68. www.psoriasis.org How Treatment Can Be Used Topicals Corticosteroids Tar Vitamin D analogs Emollients Phototherapy PUVA UVB Methotrexate Cyclosporine Retinoids Biologics PDE4 Systemic
69. 69. www.psoriasis.org Rotational Therapy Used to reduce the cumulative toxicity of treatments Treatments are rotated on intervals of one to two years Example: Methotrexate rotates with other treatments PUVA, cyclosporine or a biologic
70. 70. www.psoriasis.org Complementary Medicine Herbs/Natural remedies Aloe Vera Apple Cider Vinegar Capsaicin Dead Sea Salts Turmeric Fish Oil Vitamin D Acupuncture or acupressure
71. 71. Tips to help maximize your treatment options www.psoriasis.org
72. 72. What You Can Do www.psoriasis.org Prepare for your appointment with your provider Write down symptoms Make a list of all medications (prescription and over-the-counter) Write down your questions Keep track of your triggers Learn more about treatment options Ask about side effects vs benefits to help find a treatment that works for you Talk with your provider and give feedback
73. 73. Continue to learn: NPF Webcasts www.psoriasis.org
74. 74. Access support: One to One Program www.psoriasis.org Voice concerns and get answers to your questions about psoriasis and psoriatic arthritis To request a mentor visit www.psoriasis.org/one-to-one Improve your health with a support system
75. 75. Participate in Research Efforts www.psoriasis.org To learn more visit: http://services.psoriasis.org/clinical-trials/ DmitriyShironosov,123RFStockPhoto Clinical trials: Help develop new and better treatments Help gain a better understanding of psoriatic disease and related health conditions
76. 76. Stay current: New Treatments and Research www.psoriasis.org Advance Enews (www.psoriasis.org/enews) Receive the latest news in research, treatment and healthy living tips Team NPF Enews (www.psoriasis.org/enews) Stay current on upcoming events and how to be involved Psoriasis Advance www.psoriasis.org/advance Quarterly publication the premier source for the latest news in psoriatic disease
77. 77. Small Group Discussion www.psoriasis.org 11:40 a.m. to 12:00 p.m.
78. 78. Q & A Session www.psoriasis.org with Dr. Prussick 12:00 p.m.
79. 79. Join us and Connect with others Visit: www.teamnpf.org/DCwalk www.psoriasis.org Team NPF Walk Washington, D.C. occurs Sunday, September 27th at Lincoln Memorial Reflecting Pool
80. 80. Join us and Connect with others Team NPF Cycle Inaugural Ride Saturday, August 15, 2015 Unionville Vineyards, Ringoes, NJ www.psoriasis.org For more information contact: Robert Grabel at rgrabel@psoriasis.org
81. 81. www.psoriasis.org Our thanks to: Dr. Prussick All of you for attending Our sponsors: Amgen, AbbVie, Celgene, Janssen Biotech, Novartis Pharmaceuticals Please Complete Your Evaluation Form