A dermatologist’s guide on psoriasis oral medications
Dr. Ryan Trowbridge, board-certified dermatologist, talks about newer and traditional oral psoriasis medications and explains what makes them unique.
Table of Content:
Psoriasis medication list | Otezla | Sotyktu | Methotrexate | Cyclosporine | Acitretin | Oral medications vs biologics | FAQ
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According to Dr. Trowbridge, board-certified dermatologist, Otezla (apremilast) stands out as the most commonly utilized oral medication for psoriasis treatment, attributed to its relative safety and effectiveness, especially in comparison to older systemic treatments. It works by inhibiting an enzyme involved in the inflammatory process, making it a popular choice for patients seeking an oral treatment option with fewer serious systemic risks. It also has over a 10 years track record having been in use since 2014.
Following Otezla, Sotyktu (deucravacitinib) and Methotrexate are also frequently prescribed. Sotyktu, a newer addition to the lineup and increasing in popularity, offers a novel mechanism as a selective tyrosine kinase 2 (TYK2) inhibitor and has been recognized for its robust efficacy in clinical trials.
Methotrexate, on the other hand, is a long-standing treatment option in the management of moderate to severe psoriasis, appreciated for its cost-effectiveness and well-documented efficacy, though it does require careful monitoring due to potential liver toxicity and other side effects.
Acitretin continues to be used in some cases but is generally less favored, especially for women of child-bearing age due to its teratogenicity and tendency to remain in the body for years after being taken. It’s also less effective with a less favorable side-effect profile than many other systemic options.
Lastly, cyclosporine, once a mainstay for systemic psoriasis treatment, has seen a significant decline in use. Its potent immunosuppressive action carries a higher risk of adverse effects, and also causes nephrotoxicity and hypertension, making it a less desirable option in the face of newer treatments with better safety profiles and similar or greater efficacy. However, it can work quickly, is cost-effective, and generally safe when used for shorter periods (up to a year or 2), so it can be a good option in certain circumstances.
Xeljanz (tofacitinib), primarily used by rheumatologists, is more commonly prescribed for conditions like rheumatoid and psoriatic arthritis. Its use in psoriasis is less frequent and usually considered when there is concomitant psoriatic arthritis as it is not FDA approved for plaque psoriasis in the absence of psoriatic arthritis.
Oral psoriasis medication list
New oral medications for psoriasis treatment
Dr. Trowbridge says that from the new oral psoriasis medications, Otezla and to some extent, Sotyktu have become more popular among doctors and patients due to their targeted mechanisms of action and ease of use.
These medications provide specific intervention in the inflammatory pathways involved in psoriasis, offering significant improvements in plaque symptoms and skin clarity with a reduced burden of side effects compared to traditional systemic treatments like methotrexate, cyclosporine, and acitretin. Their oral administration makes them particularly appealing for patients who prefer pills over injectable therapies, enhancing adherence and convenience. They are also good for patients who are perhaps hesitant to commit to an injectable biologic treatment, which generally speaking are best not to stop once they have been started.
Otezla
Active ingredient | Apremilast |
Brand names | Otezla |
What does it do? | Otezla is a phosphodiesterase 4 (PDE4) inhibitor that specifically targets inflammatory pathways involved in psoriasis, leading to reduction in skin inflammation and plaque buildup. It is the leading prescribed oral medication for moderate to severe plaque psoriasis and psoriatic arthritis1. |
Typical dose | The typical starting dose is 10 mg on the first day, with a five to day day adjustment period to a gradual increase to 30 mg twice daily2. |
Manufacturer | Amgen |
Common side effects | Diarrhea, nausea, upper respiratory tract infection, depressed mood, tension headache3 |
Patient savings program | Amgen Support for Otezla |
Generic available | No |
Sotyktu
Active ingredient | Deucravacitinib |
Brand names | Sotyktu |
What does it do? | Sotyktu is a tyrosine kinase 2 (TYK2) inhibitor that modulates the immune system by targeting a specific pathway involved in inflammation. Sotyktu is used for the treatment of moderate to severe plaque psoriasis4. |
Typical dose | 6 mg once daily |
Manufacturer | Bristol Myers Squibb |
Common side effects | Upper respiratory tract infections, headache, diarrhea, nausea, herpes simplex infections5 |
Patient savings program | Sotyku Co-pay Assistance Program |
Generic available | No |
Traditional systemic treatments for psoriasis
Dr. Trowbridge says that despite the emergence of newer therapies, traditional systemic treatments such as methotrexate, cyclosporine, and acitretin (to some extent) continue to be prescribed by doctors for psoriasis due to some compelling reasons.
Firstly, these medications have a long track record of effectiveness, offering substantial relief for many patients with moderate to severe psoriasis. They are also extensively studied, which provides clinicians with a clear understanding of their efficacy, safety profiles, and management of side effects.
Additionally, they are generally less expensive than newer biologics and oral treatments, making them more accessible for patients looking for cost-efficient psoriasis treatment.
Methotrexate
Active ingredient | Methotrexate |
Brand names | Trexall, Rheumatrex |
What does it do? | Methotrexate is one of the oldest and most frequently prescribed medications for severe psoriasis. It slows down the rate of skin cell growth and can reduce inflammation. It is often used for patients with moderate to severe psoriasis and psoriatic arthritis6. |
Typical dose | For psoriasis, the dose often starts at 10 – 25 mg once a week, adjusting based on response and tolerance. It can be taken orally or administered as an injection7. |
Manufacturer | Various generic manufacturers |
Common side effects | Nausea and vomiting, fatigue, dizziness, abnormal liver function, mouth sores8 |
Patient savings program | The price of generic methotrexate tablets ranges between $20 to $30 depending on pharmacy and state. |
Generic available | Yes |
Cyclosporine
Active ingredient | Cyclosporine |
Brand names | Neoral, Gengraf |
What does it do? | Cyclosporine inhibits the immune system, specifically T-cell activation, to reduce inflammation and plaque formation. It is typically used for quick control of severe psoriasis9. |
Typical dose | The dose is weight-based and varies widely depending on the patient’s condition and response to treatment; commonly dosed up to a maximum of 2 to 2.5 mg/kg/day twice daily10. |
Manufacturer | Novartis and Abbvie |
Common side effects | High blood pressure, kidney problems, headache, increased hair growth, nausea, electrolyte abnormalities11 |
Price | The price of generic cyclosporine tablets ranges between $100 to $200 per month depending on pharmacy and state. |
Generic available | Yes |
Acitretin
Active ingredient | Acitretin |
Brand names | Soriatane |
What does it do? | Acitretin is an oral retinoid that helps normalize skin cell growth. Acitretin is particularly useful for forms of psoriasis that are resistant to other treatments, but it has several limitations and side effects, including teratogenicity, making it unsuitable for pregnant women or those planning to become pregnant12. |
Typical dose | The initial dose may range from 10 to 50 mg a few times a week or daily, adjusted based on clinical response and side effects13. |
Manufacturer | Stiefel Laboratories |
Common side effects | Dry skin, lip inflammation, peeling, skin itching, hair loss14 |
Patient savings program | The price of generic acitretin is between $120 to $200 per month.. |
Generic available | Yes |
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Psoriasis treatment: oral medications vs biologics
New oral medications and biologics used for the treatment of psoriasis offer significant benefits, but they differ in several key aspects such as mode of administration, side effects, cost, and the necessity for ongoing monitoring.
Understanding these differences between newer oral treatments for psoriasis(Otezla, Sotyktu and Xeljanz) and biologic medications (Skyrizi, Tremfya and Taltz) is crucial for patients to make informed decisions about the most appropriate treatment strategy based on individual health needs, lifestyle considerations, and specific disease characteristics.
Frequently asked questions about psoriasis pills
Is it possible to switch from psoriasis tablets to psoriasis creams?
According to Dr. Trowbridge, it is possible to step down from oral psoriasis medications to topical treatments, but this is not a common approach. Because psoriasis is chronic, and because the decision to use systemic treatments usually comes when topical treatments are determined ineffective or infeasible, stepping down to topicals once one has started systemics is most typically not a winning strategy. However, it is a reasonable approach and one that can be attempted if you and your dermatologist determine it is in your best interest. It is also one of the advantages of using oral versus injectable systemic treatments, as for the latter it is generally advised not to stop once one has started.
What is the new pill for psoriasis?
Dr. Trowbridge says that although Otezla is the most commonly prescribed oral medication for psoriasis; however, studies show that Sotyktu is rather safe and likely more effective than Otezla15
Are there oral medications for psoriasis?
Yes, there are several oral medications available for the treatment of psoriasis, which offer convenient alternatives to topical treatments and injectable biologics. Among these, methotrexate and cyclosporine are traditional systemic treatments that have been used for many years. More recently developed drugs such as Otezla and Sotyktu provide targeted approaches to managing the disease, focusing on different aspects of the immune response and inflammation typical of psoriasis.
Which is the best tablet for psoriasis?
Determining the “best” tablet for psoriasis depends on various factors including the severity of the condition, individual health profile, potential side effects, and how the patient’s body responds to the medication. However, Otezla has shown promising results in clinical trials, which means patients achieved a clear or almost clear skin after 16 weeks, and has a 10+ year track record of being prescribed for psoriasis16.
What is the most prescribed oral drug for psoriasis?
The most prescribed oral drugs for psoriasis can vary based on geographic location, healthcare systems, and clinical guidelines, but Otezla is the most commonly prescribed for psoriasis. Historically, methotrexate was one of the most frequently prescribed systemic medications due to its effectiveness, long history of use, and cost-effectiveness compared to newer therapies, and is still often used.
What is the oral solution for psoriasis?
For patients who have trouble swallowing pills or getting injections, both methotrexate and cyclosporine can be found in oral formulations. They may need to be obtained by specialty or compounding pharmacies as they are not frequently prescribed.
Article References:
https://www.otezla.com/plaque-psoriasis/safety-and-side-effects
https://www.otezlapro.com/dosing/
https://www.sotyktu.com/starting-sotyktu/once-daily-dosing
https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/040054s015,s016,s017.pdf
https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/050715s035,050716s038lbl.pdf
https://www.soriatane.com/
https://pubmed.ncbi.nlm.nih.gov/35820547/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4517531/