Methotrexate Acitretin

Systemic therapies are seldom used for mild to moderate psoriasis, and are generally reserved for patients with moderate to severe psoriasis.17 29 Oral agents include sulfasalazine, acitretin, methotrexate, cyclosporine, mycophenolate mofetil, azathioprine, tacrolimus, and hydroxyurea. Parenteral agents include the biologic response modifiers alefacept, efalizumab, etanercept, infliximab, and many others, currently at various stages of research or approval for psoriasis. 

ACITRETIN METHOTREXATE t risk of hepatotoxicity Additive hepatotoxic effects Avoid co-administration... 

Several UVB and systemic therapy combinations have shown efficacy. These include UVB with acitretin (ReUVB) and UVB with methotrexate, and will be discussed later. 

Acitretin is an oral retinoid that is likely safer than methotrexate or cyclosporine, especially when considering continuous use over many years.21 The initial dose is 25 mg/day which can be increased to a maximum of 75 mg/day if needed.17 When acitretin is used concurrently with phototherapy (ReUVB or RePUVA), there appears to be a synergistic treatment effect, and the number and duration of phototherapy sessions needed to achieve clearance is reduced.21 RePUVA is a well-established... 

Sulfasalazine is an antiinflammatory agent that inhibits 5-lipoxygenase. It is used selectively as an alternative treatment, particularly in patients with concurrent psoriatic arthritis. When used alone, it is not as effective as methotrexate, PUVA, or acitretin. However, it has a relatively high margin of safety. The usual oral dose is 3 to 4 g/day for 8 weeks. Its adverse effects are similar to other sulfonamide antibiotics. 

Contraindications Severely impaired liver or kidney function, chronic abnormal elevated lipid levels, concomitant use of methotrexate ortetracyclines, hypersensitivity to acitretin, etretinate, or other retinoids, sensitivity to parabenz (used as preservative in gelatin capsule)... 

Clinically important, potentially hazardous interactions with acitretin, antacids, cholestyramine, dapsone, furazolidone, halofantrine, hydroxychloroquine, methotrexate, methoxsalen, mivacurium, nilotinib, penicillamine, sulfonamides... 

Clinically important, potentially hazardous interactions with aceclofenac, acetazolamide, acitretin, bendroflumethiazide, benzthiazide, chlorothiazide, chlorthalidone, cocoa, desvenlafaxine, etoricoxib, fluoxetine, guarana, haloperidol, hydrochlorothiazide, hydroflumethiazide, indapamide, insulin detemir, insulin glulisine, meperidine, mesoridazine, methotrexate, methyclothiazide, metolazone, olmesartan, pegfilgrastim, phenylbutazone, polythiazide, quinethazone, rocuronium, rofecoxib, sibutramine, sulpiride, tenoxicam, thiazides, trichlormethiazide, valdecoxib, xipamide, zofenopril, zuclopenthixol... 

Clinically important, potentially hazardous interactions with acitretin, aluminum salts, amoxicillin, ampicillin, antacids, bacampicillin, bismuth, calcium, carbenicillin, cloxacillin, digoxin, iron salts, isotretinoin, magnesium salts, methotrexate, methoxyflurane, mezlocillin, nafcillin, oxacillin, penicillins, piperacillin, ticarcillin, vitamin A, zinc, zinc salts... 

Acitretin Cyclosporine Tacrolimus Methotrexate Mycophenolate mofetil Sulfasalazine 6-Thioguanine Flydroxyurea... 

Acitretin, an oral retinoid, is the active metabolite of etretinate and has demonstrated clinical effects similar to etretinate, but with fewer adverse effects. Acitretin is indicated for the treatment of severe psoriasis, including erythrodermic and generalized pustular types, but is more useful as an adjunct in the treatment of plaque psoriasis. In contrast to the fast-acting cyclosporine and methotrexate, acitretin resolves psoriatic lesions more slowly. 

Acitretin has shown good results when combined with other psoriatic therapies, including PUVA and UVB, cyclosporine, and methotrexate. The combination of acitretin and PUVA is highly effective and provides faster and more complete clearance, as well as allowing a decrease in the doses of both agents, thereby limiting the risk of adverse effects. ... 

Side effects of acitretin include dryness of mucous membranes and skin with localized exfoliation of the palms and plantar surface of the feet, skin and nail erosion and transient thinning of hair. These effects are dose-dependent and reversible. Longer-term adverse effects include ossification of ligaments and raised plasma triglycerides and cholesterol levels. Acitretin should not be taken in combination with methotrexate because of toxicity to the liver. 

Although methotrexate and etretinate have been used together with success for psoriasis, the risk of severe drug-induced hepatitis seems to be very considerably increased. One author says that he has decided not to use this combination in future. Concurrent use should clearly be undertaken with great care. Etretinate has been largely superseded by acitretin (a metabolite of etretinate, which has a shorter half-life) but some consider that the combination of methotrexate and acitretin should also be avoided. ... 

A 43-year-old man used acitretin, phototherapy, methotrexate, ciclosporin, and infliximab and had an initially good response, but then relapsed. Etanercept 50 mg twice a week for 3 months, then 25 mg twice a week, was introduced, and after 14 months he noticed black lesions over injection sites, initially on the abdomen. He then carried out injections into the thigh, where the same reactions occurred. A biopsy of a black papule was consistent with angiokeratoma. 

---