What are the best ways to manage psoriasis in elderly patients?

Hi,

Welcome to icliniq.com.

I have read your query and can understand your concern.

I am sorry to hear your father is having a tough time with his psoriasis and associated arthritis. Managing psoriasis and psoriatic arthritis, especially in elderly patients, requires a tailored approach that balances effectiveness with safety. Here’s a comprehensive plan for his situation:

1. Review of current treatment (Otezla)

Effectiveness: If the psoriasis worsens after four months, it suggests that Otezla (apremilast) may not be sufficient for him.

Side effects:

Blood pressure: Otezla is not directly known to raise blood pressure, but it is essential to evaluate other causes like stress, medications, or comorbidities.

Gastrointestinal issues: Stomach problems (nausea, diarrhea) are common with Otezla and may worsen in older adults.

2. Adjusting treatment

Given his age, worsening arthritis, and systemic issues, a shift to biological therapy may provide better control with fewer systemic side effects.

Biologics for psoriasis and psoriatic arthritis: Biologics target specific components of the immune system and are generally well-tolerated in elderly patients when appropriately monitored.

TNF-alpha inhibitors

Examples: Etanercept, Adalimumab, Infliximab.

Benefits: Effective for both skin lesions and arthritis.

Caution: Risk of infections, so monitor closely.

IL-17 inhibitors

Examples: Secukinumab, Ixekizumab.

Benefits: Very effective for psoriasis and arthritis with a good safety profile.

IL-23 inhibitors

Examples: Guselkumab, Risankizumab.

Benefits: Less frequent dosing, excellent for skin lesions and arthritis.

IL-12/23 inhibitors

Example: Ustekinumab.

Benefits: Suitable for moderate-to-severe psoriasis and arthritis, good safety profile in elderly patients.

3. Managing comorbidities

Hypertension: His elevated blood pressure (165/95) needs urgent attention.

Consult his physician to:

1. Adjust antihypertensive medications.

2. Avoid NSAIDs (nonsteroidal anti-inflammatory drugs) for arthritis pain, as they can worsen hypertension.

3. Monitor blood pressure regularly.

Gastrointestinal issues:

1. Ensure side effects are related to Otezla and not another underlying issue.

2. Consider proton pump inhibitors (PPIs) or antacids for symptomatic relief if required.

Psoriatic arthritis:

1. Arthritis progression: With a positive RF factor and high CCP antibodies, his arthritis may also have features of rheumatoid arthritis (RA). Dual management is essential.

2. Methotrexate: Low-dose methotrexate may help arthritis but requires liver monitoring.

3. Biologics: The biologics listed above can address both psoriasis and arthritis effectively.

Lifestyle adjustments:

1. Anti-inflammatory diet: Include foods rich in omega-3s (salmon, walnuts) and antioxidants (berries, leafy greens). Avoid processed foods, sugar, and excess salt to help manage blood pressure and inflammation.

2. Gentle exercise: Encourage low-impact activities like swimming or yoga to ease arthritis symptoms.

3. Skincare: Use emollients, medicated shampoos, and avoid harsh soaps to prevent skin irritation.

Next steps:

1. Switch to biologics: Discuss starting a biologic like secukinumab or ustekinumab with his rheumatologist or dermatologist.

2. Comprehensive monitoring: Regular blood tests for liver/kidney function. Infection monitoring (biologics can increase susceptibility to infections).

3. Pain management: Use acetaminophen or topical NSAIDs instead of oral NSAIDs for arthritis pain to avoid blood pressure complications.

I hope I have answered your query.

Let me know if I can assist you further.

Thank you.