Salt Lake City More Than Skin Deep May 30 2015
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Welcome to
Sheraton Salt Lake City HotelSaturday, May 30, 2015
www.psoriasis.org
Triggers, Treatments & You
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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.
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Our mission: to drive efforts to cure psoriatic disease and improve the lives of those affected
Improve access to care Expand knowledge of psoriatic disease
© N
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2014: $1.8 million
Increase research
www.psoriasis.org
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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
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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
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Join us
www.psoriasis.org
Visit: www.teamnpf.org
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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 [email protected]
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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
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Reminders
www.psoriasis.org
• Cell phones• Restrooms• Questions• Evaluation form
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“Triggers & You”
Kristina Callis Duffin, M.D., M.S.
Co-Director, Utah Psoriasis Initiative
Associate Professor,
Department of Dermatology,
University of Utah
Salt Lake City, Utah
www.psoriasis.org
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Disclosures – Dr. Callis Duffin
www.psoriasis.org
I have the following financial relationships to disclose:
• Advisor/Consultant: AbbVie, Inc., Amgen, Inc., Bristol Myers Squibb Company, Celgene Corporation, Eli Lilly & Co., Janssen Biotech, Novartis Pharmaceuticals, Pfizer, Inc., XenoPort, Inc.
• Grant/Research support: AbbVie, Inc., Amgen Inc., Bristol Myers Squibb Company, Celgene Corporation, Eli Lilly & Co., Janssen Biotech, Novartis Pharmaceuticals, Pfizer, Inc.,Stiefel Laboratories, Inc.
The National Psoriasis Foundation is solely responsible for all content and development of this program.
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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
• Related inflammation is associated with other health conditions
• Psoriatic arthritis
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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 Dermatologyhttp://www.jaad.org/article/S0190-9622(14)01001-9/pdf
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Mechanisms of Disease Psoriasis Nestle et al. N Eng J Med 361;5 July 30, 2009
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Mechanisms of Disease Psoriasis Nestle et al. N Eng J Med 361;5 July 30, 2009
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Charge!
www.psoriasis.org
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Inflammation in Psoriasis
stressed
T cells mature and propogate
Skin cells stressed, signals released
Dendritic cells activated, secrete cytokines
Other cells (neutrophils) get recruited
More cytokines
Dendritic cell
cytokines
www.psoriasis.org
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Current Research: Why You Flare
www.psoriasis.org
• One kind of Dendritic cell, “Plasmacytoid” is at work in psoriasis:
• Increased in psoriatic skin • Trigger new psoriasis flares
• A different kind of DC, “Langerhan cell” are decreased in psoriatic skin
• Allows pro-inflammatory cytokines to increase
Dendritic cell
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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)
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Triggers of psoriatic disease
www.psoriasis.org
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Psoriasis Triggers
www.psoriasis.org
• Medications: Lithium ACE inhibitors, beta-blockers Antimalarials NSAIDS (Indomethacin) Acute withdrawal of systemic or potent
corticosteroids Prednisone
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Psoriasis Triggers
www.psoriasis.org
• Infections: Strep throat Respiratory infections Staph infections Yeast
- Thrush (yeast infection in mouth)
- Other yeast infections
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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
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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
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Triggers: What You Can Do
www.psoriasis.org
• Injury to the skin:
Be careful when you know your psoriasis is
active
Treat injuries quickly. Don’t pick or scratch
bites or scabs
Use sunscreen
Talk with your provider prior to receiving a
vaccine
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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
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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
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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
• Lack of Sleep
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Triggers: What You Can Do
www.psoriasis.org
• Stress and Sleep Try meditating, mindfulness
therapy or Tai Chi to relax Spa therapy
Connect with others who
understand
Good sleep hygiene
• Weather and Environment Dress for the weather
Anticipate
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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
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Treat Your Psoriasis and Psoriatic Arthritis
www.psoriasis.org
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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
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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
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Assessing Severity of Psoriasis
www.psoriasis.org
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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
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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
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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
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10:45 a.m. Snack break
11:00 a.m. “Treatments & You”
www.psoriasis.org
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Your treatment options
www.psoriasis.org
• Topicals• Light therapy• Systemics• Biologics• PDE4
• Biosimilars• Alternative choices
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www.psoriasis.org
Topicals: What they do
• Slow growth of skin cells
• Flatten lesions
• Remove scale
• Reduce itch and inflammation
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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)
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www.psoriasis.org
Prescription Topicals
Vitamin D Derivatives Dovonex, Calcitrene (calcipotriene)
Vectical (calcitriol) Taclonex (calcipotriene and betamethasone
dipropionate)
•Vitamin A Derivatives Tazorac (tazarotene)
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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)
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www.psoriasis.org
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
• Don’t discontinue use
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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 plastic wrap, cellophane, waterproof dressing, cotton socks or a nylon suit
• Check with your provider before occluding a topical
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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
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www.psoriasis.org
Upcoming Treatments: Topicals
• Aerosal Foam (LEO 90100) Calcipotriene 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)
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www.psoriasis.org
Light Therapy
• Penetrates the skin to slow growth of skin cells
• Involves exposing the skin to a light source
• Consistency key
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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
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www.psoriasis.org
Source: Sunlight
• Natural sunlight
UVA and UVB
Short, multiple exposures
Say no to tanning beds
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www.psoriasis.org
Source: Ultraviolet light B (UVB)
• Options: Broad-band Narrow-band
• Clinic or home use
• Targeted treatment used when less than 5 percent of body surface is involved
• Whole-body treatment used when more than 5 percent of body surface area is involved
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www.psoriasis.org
Source: PUVA
• Administered in a provider’s 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
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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
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www.psoriasis.org
Risks Associated with Light Therapy
• Risks include: Sunburn Possible increased risk of skin cancer
(www.aad.org) Premature aging
Tell your provider what medications, treatments and dietary supplements you take
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www.psoriasis.org
Systemics: What they do
• Work throughout the body to:
Suppress the immune system
Stop activity of certain immune cells to slow the growth of skin cells
Reduce inflammation
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www.psoriasis.org
Methotrexate
• Weekly pills or injection
• Used to treat severe psoriasis and psoriatic arthritis
• 30% of patients will see significant improvement in three to six weeks. May take six months for complete clearance
• Use folic acid to decrease side effects
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www.psoriasis.org
Cyclosporine
• Take daily
• Take consistently
• Use to treat psoriasis
• Rapid onset• Not a good long-term drug: no longer than
one year
• May take three to four months for complete clearance
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www.psoriasis.org
Soriatane
• Oral retinoid
• SLOW for plaque psoriasis• After eight to 16 weeks of treatment,
skin lesions improve. • May take six months to reach peak
effect.
• Works best with phototherapy• Cannot use in females of childbearing
potential
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www.psoriasis.org
Risks Associated with Systemics
• Risks include: Liver disease Kidney function High blood pressure Lymphoma
• Precautions: Preconception and pregnancy Alcohol use
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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©
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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
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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 Dermatologyhttp://www.jaad.org/article/S0190-9622(14)01001-9/pdf
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www.psoriasis.org
TNF-alpha BlockersY
Biologicblocks
• Block TNF-alpha production
• Treatment options include:
-Enbrel (Etanercept) - Amgen
-Humira (Adalimumab) - AbbVie
-Remicade (Infliximab) - Janssen
-Simponi (Golimumab) - Janssen
-Cimzia (Certolizumab) - UCB
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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
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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
Y
Inhibitorblocks
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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
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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
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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
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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
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www.psoriasis.org
Upcoming Oral Agents• 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
• Tofacitinib (CP-690,550) – Pfizer
• Adenosine CF101 (Can-Fite BioPharma) A3 Receptor inhibitor for treatment of psoriasis Phase III trials
• Fumaric Acid Ester (XP23829) – XenoPort, Inc. Phase II trials Treatment of moderate-to-severe chronic plaque psoriasis
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www.psoriasis.org
Biosimilars
• Biosimilars are biologics that are chemically similar, but not identical to currently marketed 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
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www.psoriasis.org
Combination & Sequential Therapy
Topicals
• Corticosteroids
• Tar• Vit
amin D analogs
• Emollients
Phototherapy
• PUVA
• UVB
• Methotrexate
• Cyclosporine
• Retinoids
• Biologics
• PDE4
Systemic
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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
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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
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Tips to help maximize your treatment options
www.psoriasis.org
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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
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Continue to learn: NPF Webcasts
www.psoriasis.org
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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 visitwww.psoriasis.org/one-to-one
Improve your health with a support system
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Participate in Research Efforts
www.psoriasis.org
To learn more visit: http://services.psoriasis.org/clinical-trials/
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Clinical trials:
• Help develop new and better treatments
• Help gain a better understanding of psoriatic disease and related health conditions
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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
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Small Group Discussion
www.psoriasis.org
11:40 a.m. to 12:00 p.m.
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Q & A Session
www.psoriasis.org
with Dr. Callis Duffin
12:00 p.m.
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Join us and Connect with others
Visit: www.teamnpf.org
www.psoriasis.org
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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 [email protected]
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www.psoriasis.org
Our thanks to:• Dr. Callis Duffin
• All of you for attending
• Our sponsors: Amgen, AbbVie, Celgene, Janssen Biotech, Novartis Pharmaceuticals
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