New Orleans More Than Skin Deep Slide Set April 18 2015

Welcome to

Sheraton Metairie New Orleans HotelSaturday, April 18, 2015

www.psoriasis.org

Triggers, Treatments & You

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

This activity is also made possible with support from:

• Janssen BioTech, Inc.

• Novartis Pharmaceuticals, Inc.

• Tulane University School of Medicine, Dept. of Dermatology• TLCRx – Total Life Care Pharmacy

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

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2014: $1.8 million

Increase research

www.psoriasis.org

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

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

Join us

www.psoriasis.org

Visit: www.teamnpf.org

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]

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

Reminders

www.psoriasis.org

• Cell phones• Restrooms• Questions• Evaluation form

“Triggers, Treatments & You”

Erin Boh, M.D., Ph.D., F.A.A.D.

Joseph Chastain Chair,

Chairman, Department of Dermatology,

Professor of Clinical Dermatology,

and Director of the Dermatology Clinic,

Department of Dermatology

Tulane University School of Medicine

New Orleans, La.www.psoriasis.org

Disclosures – Dr. Boh

www.psoriasis.org

I have the following financial relationships to disclose:

• Speaker’s Bureau: AbbVie, Inc., Amgen, Inc., Celgene, Janssen Biotech, Eli Lilly & Co., and

Novartis Pharmaceuticals

• Investigator: Amgen, Inc., Celgene, Janssen Biotech, Novartis Pharmaceuticals and Regeneron Pharmaceuticals, Inc.

The National Psoriasis Foundation is solely responsible for all content and development of this program.

“Triggers, Treatments & You”

Andrea Murina, M.D.

Assistant Professor,

Department of Dermatology

Tulane University School of Medicine

New Orleans, La.

www.psoriasis.org

Disclosures – Dr. Murina

www.psoriasis.org

I have the following financial relationships to disclose:

• Research funding:

-Allergan, Inc. -Regeneron Pharmaceuticals, Inc. -Xoma Corporation

The National Psoriasis Foundation is solely responsible for all content and development of this program.

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

• May cause persistent warmth and swelling (inflammation) around a joint

• Related inflammation is associated with other health conditions

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

Current Research: Why You Flare

www.psoriasis.org

• Dendritic cells (DCs) are a type of immune cell that play a role in psoriatic disease

• One kind of DCs, Plasmacytoid dendritic cells might trigger new psoriasis flares

• Plasmacytoid DCs are increased in psoriatic skin

• A different kind of DC, Langerhan cells are decreased in psoriatic skin. This decrease allows pro-inflammatory cytokines to increase

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)

Triggers of psoriatic disease

www.psoriasis.org

Psoriasis Triggers

www.psoriasis.org

• Medications: Lithium Inderal, ACE inhibitors, beta-blockers Antimalarials NSAIDS (Indomethacin) Tetracyclines Acute withdrawal of systemic or potent

corticosteroids Prednisone

Psoriasis Triggers

www.psoriasis.org

• Infections: Strep throat Respiratory infections Staph Thrush (yeast infection

in the mouth) Yeast Earache

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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

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

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

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

Triggers: What You Can Do

www.psoriasis.org

• Stress Try meditating, mindfulness therapy

or Tai Chi to relax Spa therapy

Connect with others who

understand

• Weather Stay warm, place heating pads over

painful joints, wear gloves

Try non-weight-bearing exercises to

improve joint function

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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

Treat Your Psoriasis and Psoriatic Arthritis

www.psoriasis.org

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

Assessing Severity of Psoriasis

www.psoriasis.org

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

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

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

10:45 a.m. Snack break

11:00 a.m. “Your Treatment Options”

www.psoriasis.org

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

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)

www.psoriasis.org

Prescription Topicals

Vitamin D Derivatives Dovonex (calcipotriene) Vectical (calcitriol) Taclonex (calcipotriene and betamethasone

dipropionate)

•Vitamin A Derivatives Tazorac (tazarotene)

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)

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

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

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

www.psoriasis.org

Upcoming Treatments: Topicals

• Aerosal Foam (LEO 90100) Calcipotriol 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)

www.psoriasis.org

Light Therapy

• Penetrates the skin to slow growth of skin cells

• Involves exposing the skin to a light source

• Consistency key

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

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 5-10 percent of body surface is covered

• Whole-body treatment used when more than 5 percent of body surface area is covered

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

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

www.psoriasis.org

Risks Associated with Light Therapy

• Risks include: Sunburn Skin cancer (www.aad.org) Premature aging Cataracts (PUVA)

Tell your provider what medications, treatments and dietary supplements you take

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

www.psoriasis.org

Methotrexate

• Take once a week• Used to treat severe

psoriasis and psoriatic arthritis

• See improvement in three to six weeks. May take six months for complete clearance

• Use folic acid to decrease side effects

• Sometimes used to rotate with other treatments

• Can be used with biologics to prevent resistance and increase

response

www.psoriasis.org

Cyclosporine

• Take daily• Take consistently• Use to treat

psoriasis• Use no longer than

one year, lifetime use

• May take three to four months for complete clearance

• Avoid grapefruit, potassium-rich diet, St. John’s Wort, certain medications interact

• Protect your skin while in the sun

• OK to use with topical corticosteroids, vitamin D treatments

www.psoriasis.org

Soriatane

• Oral retinoid

• Take once a day with food

• Psoriasis may worsen before clearing

• After eight to 16 weeks of treatment, skin lesions improve. May take six months to reach peak effect.

• Works slowly for plaque psoriasis

• Used to treat severe psoriasis

• Rarely clears psoriasis alone

• Works best with phototherapy

• Don’t donate blood

www.psoriasis.org

Risks Associated with Systemics

• Risks include: Liver disease Kidney function High blood pressure Lymphoma

• Precautions: Preconception and pregnancy Alcohol use

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

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

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

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

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

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Inhibitorblocks

www.psoriasis.org

Upcoming IL-17 Inhibitors

• Brodalumab (AMG827) – Amgen Monoclonal antibody against IL-17 RA receptors Treatment of psoriasis and psoriatic arthritis

Phase III trials

• Ixekizumab (ILY2439821) – Eli Lilly Monoclonal antibody against IL-17A protein cells Treatment of psoriasis and psoriatic arthritis Phase III trials

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

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

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

www.psoriasis.org

Upcoming Oral Agents

• Tofacitinib (CP-690,550) – Pfizer

• 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

• Adenosine CF101 (Can-Fite BioPharma) A3 Receptor inhibitor for treatment of psoriasis Phase III trials

www.psoriasis.org

Biosimilars

• Biosimilars are not chemically identical to 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

www.psoriasis.org

Combination & Sequential Therapy

Topicals

• Corticosteroids

• Tar• Vit

amin D analogs

• Emollients

Phototherapy

• PUVA

• UVB

• Methotrexate

• Cyclosporine

• Retinoids

• Biologics

• PDE4

Systemic

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

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

Tips to help maximize your treatment options

www.psoriasis.org

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

Continue to learn: NPF Webcasts

www.psoriasis.org

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

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

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

Small Group Discussion

www.psoriasis.org

11:40 a.m. to 12:00 p.m.

Q & A Session

www.psoriasis.org

with Dr. Boh & Dr. Murina

12:00 p.m.

Join us and Connect with others

Visit: www.teamnpf.org

www.psoriasis.org

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]

www.psoriasis.org

Our thanks to:• Dr. Boh and Dr. Murina• All of you for attending• Our sponsors:

Amgen, AbbVie, Celgene, Janssen Biotech, Novartis Pharmaceuticals

• Our local supporters: Tulane University School of Medicine, Dept. of Dermatology and TLCRx

Please Complete Your Evaluation Form