Retinoids Methotrexate

Psoriasis Neoral and Gengraf are indicated for the treatment of adult, nonimmunocompromised patients with severe (ie, extensive and/or disabling), recalcitrant, plaque psoriasis who have failed to respond to at least 1 systemic therapy (eg, PUVA, retinoids, methotrexate) or in patients for whom other systemic therapies are contraindicated or cannot be tolerated. While rebound rarely occurs, most patients will experience relapse with Neoral or Gengraf as with other therapies upon cessation of treatment. 

UVA can be used with other systemic agents including oral retinoids (RePUVA) and methotrexate. This will be discussed later in greater detail. 

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... 

UVB light (290 to 320 nm) therapy is an important phototherapeutic intervention for psoriasis. The most effective wavelength is 310 to 315 nm, which led to development of a UVB narrowband light source, in which 83% of the UVB emission is at 310 to 313 nm. Topical and systemic psoriatic therapies are used adj unctively to hasten and improve the response to UVB phototherapy. Emollients enhance efficacy of UVB and can be applied just before treatments. Combining short-contact anthralin, calcipotriene, or topical retinoids to UVB may also improve results. However, topical application should be done after or at least 2 hours before UVB therapy because phototherapy can inactivate the topical product. UVB phototherapy may also be more effective when added to systemic treatments such as methotrexate and oral retinoids. 

Exposure to the fetus in the first 2 weeks after conception may have an all or nothing effect (i.e., could destroy the embryo or have no ill effect). Exposure during the period of organogenesis (18 to 60 days postconception) may result in structural anomalies (e.g., methotrexate, cyclophosphamide, diethylstilbestrol, lithium, retinoids, thalidomide, certain antiepileptic drugs, and coumarin derivative). 

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)... 

METHOTREXATE RETINOIDS-ACITRETIN t methotrexate levels Uncertain Avoid co-administration... 

Clinically important, potentially hazardous interactions with acitretin, aluminum hydroxide, amoxicillin, ampicillin, antacids, bacampicillin, betamethasone, bismuth, bromelain, calcium, carbenicillin, cholestyramine, doxacillin, corticosteroids, dairy products, dicloxacillin, didanosine, digoxin, food, glidazide, iron, isotretinoin, methicillin, methotrexate, methoxyflurane, mezlocillin, nafcillin, oxacillin, penicillins, piperacillin, retinoids, rocuronium, strontium ranelate, sucralfate, ticarcillin, vitamin A, zinc... 

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. 

Harrises PV, Peat M, Janies R, Orrell D Methotrexate and retinoids in cc ibination fee psoriasis Lancet 9Zl) ii, 512... 

About 20% of cases of advanced breast cancer respond to hormone therapy and another 48% to antimetabolites such as 5-fluorouracil and cyclophosphamide (Brule et a/., 1973). But here, as in the chemotherapy of ovarian cancer, the figures refer to survival time rather than cure. Current interest centers on (a) prevention of the recurrence of postoperative breast cancer with a combination of methotrexate, fluorouracil, and cyclophosphamide (Bonadonna et al.y 1976), and (b) in the clinical trials now being conducted on this and other epitheliomas, most dreaded of all solid tumours, with adriamycin and the retinoids (see Sections 4.0 and 5.0 respectively). 

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