Which Immunosuppressants for AD, Psoriasis Are Associated With Higher AE Monitoring?

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Frequency of clinical and laboratory monitoring for adverse events in patients with atopic dermatitis or psoriasis prescribed certain systemic immunosuppressant therapies may be questionable and reflect a gap between knowledge and practice.

Treatment with cyclosporine, methotrexate, or mycophenolate is associated with more testing of blood pressure (BP), complete blood count (CBC), liver function (LFT), renal function (RFT), and lipid panels by dermatologists in adults with atopic dermatitis (AD) and psoriasis compared with patients who are not prescribed immunosuppressants, according to study findings published in the Journal of the American Academy of Dermatology.

Researchers used data from the 1993-2015 National Ambulatory Medical Care Survey to examine adult dermatology visits for AD or psoriasis. The most commonly prescribed immunosuppressant in patients with AD was cyclosporine (number of prescriptions, 166,287; 95% CI, 36,672-295,902). Other immunosuppressants prescribed in the AD population were methotrexate (number of prescriptions, 123,489; 95% CI, 23,749-223,228), azathioprine (number of prescriptions, 118,490; 95% CI, 5,266-231,714), and mycophenolate (number of prescriptions, 31,404; 95% CI, 0-54,203).

Screening was higher for BP, CBC, LFT, RFT, and lipids in patients with AD who were prescribed cyclosporine vs no immunosuppressants. In addition, mycophenolate was associated with increased testing for CBC, LFT, RFT, and lipids in this group (P <.001), and methotrexate was associated with increased testing for CBC.

In patients with psoriasis, the most commonly prescribed drug was methotrexate (number of prescriptions, 2,003,239; 95% CI, 1,442,108-2,564,370), followed by cyclosporine (number of prescriptions, 259,910; 95% CI, 102,349-417,472), azathioprine (number of prescriptions, 76,891; 95% CI, 0-186,672), and mycophenolate (number of prescriptions, 8,513; 95% CI, 0-25,303). Treatment with cyclosporine vs no immunosuppressants was associated with increased BP, CBC, lipids, and urinalysis testing in patients with psoriasis. Methotrexate was linked to increased CBC, lipids, and urinalysis testing; mycophenolate was associated with increased CBC and LFT testing (P <.001).

The study found that patients with AD or psoriasis who were prescribed cyclosporine were screened for hypertension less often than patients with AD or psoriasis not receiving cyclosporine treatment. The investigators also noted that RFT and LFT were performed in all the patients with AD, but not the patients with psoriasis on cyclosporine. Patients with AD or psoriasis treated with methotrexate rarely had LFT, RFT, or CBC testing. Although methotrexate can be administered safely long-term, the researchers acknowledged that its association with adverse events suggest that closer monitoring than that seen in this study is merited. In addition, they found that LFT and/or RFT testing was performed more commonly in patients prescribed mycophenolate than patients prescribed methotrexate or cyclosporine, which have been linked to hepatic and renal adverse events.

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Study limitations included the cross-sectional nature of sampling visits and the selection of visits from a 1-week reporting period.

The investigators believe that “this survey suggests there may be practice gaps for dermatologists in the monitoring of adverse events from immunosuppressants.”

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Singh P, Silverberg JI. Adverse-event monitoring in patients on oral systemic medications for inflammatory skin disease [published online February 20, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2020.02.043