Immunosuppressant agents These agents inhibit key factors in the immune system that are responsible for inflammatory responses.
Methotrexate (Rheumatrex) Antimetabolite that inhibits dihydrofolate reductase, thereby hindering DNA synthesis and cell reproduction. Adjust dose gradually to attain satisfactory response. 2.5 mg/wk PO/IM initially; administer 3 doses over a 24-h period, then titrate to as high as 25 mg/wk depending on response, But the data imply that methotrexate is benefi cial for synovitis but there is no evidence of benefi t for axial disease. Should be avoided in pregnancy, You should Monitor CBC counts monthly and liver and renal function every1-3months during therapy (monitor more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels, eg, dehydration); has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant decrease in blood cell counts occur; fatal reactions reported when administered concurrently with NSAIDs .
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral MTX; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response; probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides (including TMP-SMZ) can increase plasma levels; may decrease phenytoin plasma levels; may increase thiopurine plasma levels. Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency.
Cyclosporine (Sandimmune, Neoral) Cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions, such as delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft versus host disease for a variety of organs. Demonstrated to be helpful in a variety of skin disorders, especially psoriasis. The adult dose is 2.5-5 mg/kg/d PO in divided doses and the same as pediatrics . In a trial comparing methotrexate to ciclosporin , ciclosporin 3–5 mg/kg/day produced signify cant improvement in clinical and serological measures of severity of psoriatic arthritis . Long-term use of ciclosporin may control progression of radiological damage in peripheral joints.Evaluate renal and liver functions often by measuring(blood urea nitrogen) BUN, serum creatinine, serum bilirubin, and liver enzyme levels; may increase risk of infection and lymphoma; reserve IV use only for patients who cannot take orally .
Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin . Documented hypersensitivity; uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UV-B radiation in psoriasis because may increase risk of cancer .
DMARDs have been investigated and advocated for the treatment of psoriatic arthritis, none of which has been subject to good randomized controlled trials. Leflunomide (a pyrimidine synthesis inhibitor effective for rheumatoid arthritis) appeared to have some benefit in psoriatic arthritis in both the short term (3 months) and long term (2 years) in a longitudinal study of eight patients . You should note that Drugs that treat arthritis, but may worsen psoriasis such as Gold, Systemic corticosteroids and Hydroxychloroquine. Drugs that treat psoriasis, but may worsen arthritis Acitretin and Efalizumab .
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