Apremilast mechanism of action and application to psoriasis and psoriatic arthritis. Biochem Pharmacol. 2012;83:1583-1590. [PMID: 22257911 DOI: 10.1016/j.bcp.2012.01.001]

Pathophysiology of Atopic Dermatitis and Psoriasis: Implications for Management in Children

Atopic dermatitis (AD) and psoriasis are chronic inflammatory skin diseases associated with a significant cutaneous and systemic burden of disease as well as a poor health-related quality of life. Here, we review the complex pathophysiology of both AD and psoriasis and discuss the implications for treatment with current state-of-the-art and emerging topical and systemic therapies. Both AD and psoriasis are caused by a complex combination of immune dysregulation, skin-barrier disruption, genetic factors, and environmental influences. Previous treatments for both diseases were limited to anti-inflammatory agents that broadly suppress inflammation. Emerging insights into relevant pathways, including recognition of the role of T-helper type 2 driven inflammation in AD and T-helper 1 and 17 driven inflammation in psoriasis, have led to a therapeutic revolution. There are a number of novel treatment options available for AD and psoriasis with many more currently under investigation.

[Gastrointestinal side effects of apremilast : Characterization and management]

Apremilast is an oral inhibitor of phosphodiesterase-4 (PDE4) that is licensed for the second-line treatment of psoriasis and psoriatic arthritis. Data from several phase III clinical trials and real-world studies showed a good benefit-risk profile, with diarrhea and nausea as the most common adverse events. Diarrhea and nausea most frequently occurred during the first month of treatment. In most cases, they were mild or moderate in severity and tended to resolve over time with continued dosing and without intervention. In this review we summarize available data on gastrointestinal side effects of apremilast in patients with psoriasis and psoriasis arthritis and provide practical strategies for managing these symptoms.

Biological and synthetic target DMARDs in psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic multi-faceted immune-mediated systemic disorder, characterized by articular, cutaneous, enthesis, nail and spine involvement. Articular manifestations of PsA are particularly common and highly disabling for patients, while the heterogeneous clinical subsets of the disease are challenging for clinicians. In recent years, research has made many advances in understanding the pathogenesis of the disease from genetic, epigenetic and molecular points of view. New drugs are now available for the treatment of this condition, and, in particular, TNF-alfa inhibitors, historically the first biologicals approved in PsA, are now juxtaposed by new biological disease modifying anti-rheumatic drugs (bDMARDs) with different modes of action. Targeting IL-12/IL-23 p40 common subunit with ustekinumab, IL-17A with secukinumab and ixekizumab, T cells co-stimulation with abatacept, is now possible, safe and effective. Moreover, targeted synthetic molecules with oral administration are available, with the possibility to interfere with phosphodiesterase-4 and JAK/STAT pathways. Indeed, new drugs are under development, with the possibility to target selectively IL-17 receptor, IL-23, and other key molecular targets in the pathogenesis of this condition. In this narrative review, we provide an up-to-date overview of the current application of biological and targeted synthetic DMARDs in the field of PsA, with particular regard to the clinical significance of this possibility to target a higher number of distinct immune-pathways.

Understanding the formation of apremilast cocrystals

Apremilast (APR), an anti-psoriatic agent, easily forms isostructural cocrystals and solvates with aromatic entities, often disobeying at the same time Kitaigorodsky's rule as to the saturation of possible hydrogen-bonding sites. In this paper the reasons for this peculiar behavior are investigated, employing a joint experimental and theoretical approach. This includes the design of cocrystals with coformers having a high propensity towards the formation of both aromatic-aromatic and hydrogen-bonding interactions, determination of their structure, using solid-state NMR spectroscopy and X-ray crystallography, as well as calculations of stabilization energies of formation of the obtained cocrystals, followed by crystal structure prediction calculations and solubility measurements. The findings indicate that the stabilization energies of cocrystal formation are positive in all cases, which results from strain in the APR conformation in these crystal forms. On the other hand, solubility measurements show that the Gibbs free energy of formation of the apremilast:picolinamide cocrystal is negative, suggesting that the formation of the studied cocrystals is entropy driven. This entropic stabilization is associated with the disorder observed in almost all known cocrystals and solvates of APR.

Treatment of Severe Hailey-Hailey Disease With Apremilast

Importance

Hailey-Hailey disease (HHD) is a rare, autosomal-dominant acantholytic dermatosis characterized clinically by development of recurrent blisters and erosions in friction areas. Despite progression in our understanding of the molecular genetics of HHD, therapy remains suboptimal and there is no known cure.

Objective

To determine whether the novel phosphodiesterase-4 inhibitor apremilast is effective in the treatment of HHD.

Design, Setting, and Participants

Clinical case series of 4 patients with severe, treatment-resistant HHD at an outpatient clinic in the Department of Dermatology of Nice University Hospital, Nice, France. The patients were treated with apremilast; after the initial titration, the dose was 30 mg, twice daily.

Main Outcomes and Measures

Objective clinical response was assessed by the treating dermatologist using the physician global assessment score; recorded adverse effects were monitored throughout the treatment at intervals of 2 to 3 months.

Results

Three women and 1 man, with a mean age of 56 years, were treated and followed up for 6 to 10 months. Family history of the disease was noted in 3 (75%) of the cases. The lesions affected the axillary regions (75%), submammary regions (75%), inguinal regions (100%), and back and neck areas (50%). An improvement in the symptoms was reported by all of the patients after a treatment period of 1 month. After 6 months, the improvement of HHD lesions was reported as moderate to almost cleared among the patients. However, 2 patients developed some flares after 6 to 10 months of treatment and stopped apremilast therapy. One of the patients developed uncontrolled diffuse lesions and apremilast was reintroduced, resulting in partial control of her disease.

Conclusions and Relevance

Apremilast appears to offer a low-risk therapeutic alternative or adjunct in resistant and severe forms of HHD. A prospective controlled trial with long-term follow-up is required to confirm these preliminary observations.

Relative efficacy and safety of apremilast, secukinumab, and ustekinumab for the treatment of psoriatic arthritis

OBJECTIVE

To assess the relative efficacy and safety of apremilast, secukinumab, and ustekinumab at different doses in patients with active psoriatic arthritis (PsA).

METHOD

A Bayesian network meta-analysis was conducted, which included randomized controlled trials (RCTs) that examined the efficacy and safety of apremilast 20 mg, apremilast 30 mg, secukinumab 75 mg, secukinumab 150 mg, secukinumab 300 mg, ustekinumab 45 mg, and ustekinumab 90 mg compared with placebo.

RESULTS

Of the RCTs 8 comprising 3289 patients met the inclusion criteria. The American College of Rheumatology (ACR) 20 response rate was significantly higher in the secukinumab 300 mg group than in the placebo group (odds ratio OR, 7.55; 95% confidence interval CI, 3.18-17.63). Secukinumab 150 mg, secukinumab 75 mg, ustekinumab 90 mg, apremilast 30 mg, apremilast 20 mg, and ustekinumab 45 mg were also more efficacious than placebo. There were no significant differences in the efficacy between the interventions. A dose-response relationship among the same drug groups was observed. The number of serious adverse events was not significantly different among the apremilast, secukinumab, ustekinumab, and placebo groups.

CONCLUSION

All drug treatments were more efficacious than placebo; however, there were no significant differences in the efficacy and safety between the drugs at the different doses.

Apremilast induced chronic diarrhea and malnutrition

Apremilast is used as a systemic therapy for the treatment of psoriasis and psoriatic arthritis. This drug is considered relatively safe with a very low incidence of serious side effects. Common side effects are diarrhea, nausea, headache, nasopharyngitis, upper respiratory tract infections which are mild to moderate in severity. Diarrhea tends to occur within 2 weeks of starting treatment and resolve spontaneously within 4 weeks without dose adjustment or discontinuation of therapy. Chronic diarrhea and malnutrition due to apremilast have not been reported yet. We report a case of apremilast induced chronic diarrhea leading to malnutrition, necessitating discontinuation of therapy.

Phosphodiesterase-4 inhibitor in the treatment of psoriasis and psoriatic arthritis

Treatment of psoriasis and psoriatic arthritis, especially moderate and severe, represents difficulties. Recently, various methods of molecular medicine have been actively developed, however, targeted therapy deserves special attention, which consists of chemical agents that have specific target as a specific protein or enzyme. Targeted therapy is a promising direction in many branches of medicine, especially in dermatology.

Despite the wide range of biological products, their use may be accompanied by an increased risk of infectious processes and malignant neoplasms, which makes the search for a new pharmacological solution in targeted therapy even more relevant.

This review presents the possibilities and prospects for the therapeutic use of the phosphodiesterase-4 inhibitor from the group of small molecules — apremilast, primarily in the treatment of psoriasis and psoriatic arthritis.

Treatment of moderate to severe psoriasis with apremilast over 2 years in the context of long-term treated HIV infection: A case report

Treatment of moderate-to-severe psoriasis in patients with HIV infection is a clinical challenge. We present the case of a patient with a longstanding history of well-controlled HIV. He had failed topical management, and his hypertriglyceridemia made use of acitretin potentially unsafe. He was unable to regularly attend a phototherapy unit. Physical examination revealed 12% total body surface area involvement with a Psoriasis Area Severity Index (PASI) of 10.2. His Dermatology Quality of Life Index (DLQI) was 20. After 3 months of apremilast treatment, his PASI decreased to 4.1. After 7 months, his PASI decreased to 2.7 and his DLQI to 1. Two years later, his PASI score was 2.4, with a stable CD4 count of 1200 cells/mm³ and an undetectable viral load. There were no serious opportunistic infections or laboratory abnormalities. To our knowledge, this represents the second reported case of psoriasis treatment with apremilast in a patient with HIV.

Nails as immune-privileged sites: A case of disabling Acrodermatitis continua of Hallopeau successfully treated with Apremilast

Acrodermatitis continua of Hallopeau (ACH) is a chronic, inflammatory, and relapsing disorder characterized by the progressive destruction of fingernails and toenails. This condition is rare, difficult to treat, and often misdiagnosed. Several antipsoriatic treatments have been used, without any therapeutic guideline and no real improvement. Apremilast is an oral phosphodiesterase 4 inhibitor, approved for the treatment of chronic plaque psoriasis and psoriatic arthritis. It increases the intracellular concentration of cAMP and restores cytokine equilibrium, especially IL-10, which is particularly involved in nail psoriasis. We reported the case of a 58-year-old man affected by ACH, successfully treated with Apremilast, who achieved a complete healing in just 1 month of treatment without any side effect. We suggest this drug as a successful new treatment for ACH, which can improve clinical manifestations rapidly and has no or few adverse effects. Future formal clinical trials and additional case reports are needed to establish the safety and efficacy of Apremilast in the treatment of ACH.

Comparison of the Efficacy and Safety of Tofacitinib and Apremilast in Patients with Active Psoriatic Arthritis: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Tofacitinib and apremilast have shown considerable efficacy in placebo-controlled trials of active psoriatic arthritis, but the relative efficacy and safety remain unclear because of a lack of head-to-head comparisons.

OBJECTIVE

The aim of this study was to assess the relative efficacy and safety of tofacitinib and apremilast at different doses in patients with active psoriatic arthritis.

METHOD

We performed a Bayesian network meta-analysis to combine evidence from randomized controlled trials for examination of the efficacy and safety of tofacitinib 10 mg, tofacitinib 5 mg, apremilast 30 mg, and apremilast 20 mg in psoriatic arthritis.

RESULTS

Eight randomized controlled trials including 3086 patients met the inclusion criteria. There were ten pairwise comparisons including six direct comparisons of five interventions. All the interventions achieved a significant American College of Rheumatology 20 response compared with placebo. Tofacitinib 10 mg and apremilast 30 mg were among the most effective treatments for active psoriatic arthritis, followed by tofacitinib 5 mg, and apremilast 20 mg. The ranking probability based on the surface under the cumulative ranking curve (SUCRA) indicated that tofacitinib 10 mg had the highest probability of being the best treatment in terms of the American College of Rheumatology 20 response rate (SUCRA = 0.785). This was followed by apremilast 30 mg (SUCRA = 0.670), tofacitinib 5 mg (SUCRA = 0.596), apremilast 20 mg (SUCRA = 0.448), and placebo (SUCRA = 0.001). We observed no significant differences in the incidence of serious adverse events after treatment with tofacitinib 10 mg, apremilast 30 mg, tofacitinib 5 mg, apremilast 20 mg, or placebo.

CONCLUSIONS

In patients with active psoriatic arthritis, tofacitinib 10 mg and apremilast 30 mg were the most efficacious interventions and were not associated with a significant risk of serious adverse events.

Novel Non-biologic Targets for Inflammatory Bowel Disease

PURPOSE OF REVIEW

The biologic era revolutionized the medical management of inflammatory bowel disease (IBD) and allowed for a paradigm shift away from a therapeutic strategy that traditionally relied on corticosteroids and immunomodulators. IBD treatment has now further evolved to encompass novel non-biologic agents.

RECENT FINDINGS

An electronic database search, spanning up to September 2018, was conducted using PubMed, Web of Science, Google Scholar, and Scopus. Abstracts were also reviewed from Digestive Diseases Week, European Crohn's and Colitis Organization congress, Canadian Digestive Diseases Week, and United European Gastroenterology Week. The JAK1/3 inhibitor, tofacitinib, was shown to both induce and maintain clinical remission and mucosal healing in ulcerative colitis (UC). Also, the sphingosine-1-phosphate (SIP) S1P1/S1P5 receptor agonist ozanimod showed benefit with clinical remission and mucosal healing in UC. Anti-trafficking non-biologic therapies such as AJM300 and a phosphodiesterase (PDE) PDE4 inhibitor, apremilast, have shown benefit in terms of clinical response, clinical remission, and mucosal healing in UC. Upadacitinib and filgotinib have shown initial favorable outcomes in CD patients, with further ongoing trials. Non-biologic agents comprise a growing number of mechanisms of action with the promise of safe and effective oral therapy for patients with IBD.

Cascade Signals of Papaverine Inhibiting LPS-Induced Retinal Microglial Activation

Studies have shown that papaverine can inhibit lipopolysaccharide (LPS)-induced microglial activation. The retinal primary microglia of newborn SD rats were isolated and purified, and a LPS-induced microglia activation model was established. The protein phosphorylation level of the signaling pathway was detected by western blotting. The transcription and expression of TNF-α, IL-1β, and IL-10 were respectively detected by RT-PCR and ELISA to observe the abnormal activation of primary microglia. The cAMP inhibitor Rp-isomer, PKA inhibitor H89, and MEK inhibitor U0126 were separately added to further investigate the role of MEK/Erk in PAP inhibition of primary microglial activation and the relationship between cAMP/PKA and MEK/Erk. It was found that the level of MEK phosphorylation was upregulated after LPS stimulation, which was blocked by 10 μg/ml of papaverine.10μM U0126 significantly inhibited TNF-α and IL-1β and increased IL-10 transcription and expression in retinal microglia (P < 0.01). Both Rp-isomer and H89 upregulated the phosphorylation levels of MEK and Erk. Papaverine may inhibit inflammatory factors and promote the expression of anti-inflammatory factors through the cAMP/PKA and MEK/Erk pathway, thereby inhibiting LPS-induced activation of primary retinal microglia, and the MEK/Erk pathway may be partially regulated by cAMP/PKA, which can provide theoretical basis and experimental basis for its protection of the central nervous system.

Topical, systemic and biologic therapies in hidradenitis suppurativa: pathogenic insights by examining therapeutic mechanisms

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin, manifesting in chronic, recurrent painful pustules, nodules, boils and purulent draining abscesses. Our current understanding of the pathogenesis of the disease is incomplete. This review aims to identify available treatment options in HS and discuss the pharmacological mechanisms through which such agents function. Identifying common pathways may inform our understanding of the pathogenesis of HS as well as identify future therapeutic targets. The pharmacological mechanisms implicated in topical therapies, antibiotic, hormonal, systemic immunomodulatory and biologic therapies for HS are discussed. Significant differences exist between agents and implicated pathways in therapy for mild and severe disease. This is an expression of the possible dichotomy in inflammatory pathways (and treatment responses) in HS. Studies involving monoclonal antibodies provide the greatest insight into what these specific mechanisms may be. Their variable levels of clinical efficacy compared with placebo bolsters the suggestion that differential inflammatory pathways may be involved in different presentations and severity of disease. Nuclear factor kappa B (NF-κB), tumor necrosis factor (TNF)-α and other innate immune mechanisms are strongly represented in treatments which are effective in mild to moderate disease in the absence of scarring or draining fistulae, however complex feed-forward mechanisms in severe disease respond to interleukin (IL)-1 inhibition but are less likely to respond to innate immune inhibition (through NF-κB or TNF-α) alone. It is unclear whether IL-17 inhibition will parallel TNF-α or IL-1 inhibition in effect, however it is plausible that small molecule targets (Janus kinase1 and phosphodiesterase 4) may provide effective new strategies for treatment of HS.

Complete resolution of erythrodermic psoriasis with first-line apremilast monotherapy

Erythrodermic psoriasis (EP) is the most serious type of psoriasis with high morbidity and mortality. First-line recommended therapies for EP, cyclosporine and infliximab have significant adverse effects. Cyclosporine increases the risk of hypertension, leucopenia, infections and renal failure. Infliximab increases the risk of reactivation of tuberculosis, hepatitis B and histoplasmosis, and increases risk for hepatitis, autoantibody formation, congestive heart failure, demyelinating disorders, pancytopenia, lymphoma and skin cancer. An effective drug with a much safer side effect profile will be of significant benefit in EP. The phosphodiesterase 4 inhibitor apremilast is U.S Food and Drug Administration (FDA) approved for plaque psoriasis and psoriatic arthritis. Adverse effects of apremilast reported are headache, nausea, diarrhoea, upper respiratory tract infection, potential for depression and weight loss. We report complete and long-standing resolution of EP with first-line apremilast monotherapy. Apremilast may be an effective option with comparatively minor side effects for EP.

Apremilast in Psoriasis and Beyond: Big Hopes on a Small Molecule

Apremilast, an orally administered small molecule inhibitor of phosphodiesterase 4 (PDE4), has been licensed by the US Food and Drug Administration for the management of active psoriatic arthritis (March 21, 2014) and moderate to severe plaque psoriasis (September 23, 2014). It has got approval from Drug Controller General of India for marketing in India in 2017. The drug has drawn much attention from the practising dermatologists for its commendable safety profile and prescription convenience. Introduced initially as an orally administered small molecule in psoriasis patients, the drug has now been used in various other indications as evident by the recent surge in literature for its off-label uses. Being a relatively new drug in the treatment armamentarium of psoriasis and other inflammatory dermatoses; in this review, we will discuss various practical aspects of prescribing oral apremilast, based on the current and emerging literature.

A randomized placebo-controlled single-center pilot study of the safety and efficacy of apremilast in subjects with moderate-to-severe alopecia areata

Alopecia areata (AA) is a common autoimmune disease that results in non-scarring hair loss. AA pathogenesis is thought to involve multiple inflammatory cytokines. Apremilast is a phosphodiesterase 4 (PDE4) inhibitor that reduces pro-inflammatory cytokine production. Recent studies demonstrate upregulation of PDE4 in human scalp lesions of AA patients and hair regrowth in a humanized AA mouse model upon apremilast treatment, suggesting a possible potential of apremilast in AA. To assess the efficacy and safety of apremilast in AA, we conducted a double-blind, placebo-controlled single-center pilot study in 30 moderate-to-severe AA patients (≥ 50% scalp involvement) that were randomized 2:1 to receive apremilast (n = 20) or placebo (n = 10) orally for 24 weeks. The primary endpoint was the percentage of patients achieving 50% reduction in severity of alopecia tool (SALT) score (SALT₅₀) at 24 weeks compared to baseline, and the secondary endpoints included the percent change in SALT score at weeks 24 and 48. Eight patients in the apremilast arm withdrew prior to week 24 along with two patients in the placebo group, mostly due to lack of efficacy and adverse events. At 24 weeks, only 1 of 12 apremilast-treated subjects achieved SALT₅₀, and similarly 1 of 8 placebo-treated subjects achieved SALT₅₀. The difference between the mean percent improvement in SALT score at week 24 compared to baseline of the two study arms was not statistically significant (p = 0.38). The lack of treatment response in most of our patients argues against a pathogenic role for PDE4 specifically in moderate-to-severe AA, but targeting this pathway may still be of value in patients with mild AA as there is less of an inflammatory burden in this population. However, future larger studies may be needed to conclude apremilast's lack of efficacy in moderate-to-severe AA.

Practical Pearls About Current Rheumatic Medications

New and existing rheumatic disease is frequently encountered in the primary care setting. The number of medications used to treat various rheumatic conditions continues to increase. Some medications have very specific indications, whereas others have increasing off-label uses. Regardless of the indication, the medications used in rheumatology have variable dosing recommendations, significant side effects, recommended monitoring parameters, and potential medication interactions. Clinicians need to be aware of the potential uses as well as possible pitfalls associated with medications used in rheumatology.

Phosphodiesterase-4 Inhibitors for the Treatment of Inflammatory Diseases

Phosphodiesterase-4 (PDE4), mainly present in immune cells, epithelial cells, and brain cells, manifests as an intracellular non-receptor enzyme that modulates inflammation and epithelial integrity. Inhibition of PDE4 is predicted to have diverse effects via the elevation of the level of cyclic adenosine monophosphate (cAMP) and the subsequent regulation of a wide array of genes and proteins. It has been identified that PDE4 is a promising therapeutic target for the treatment of diverse pulmonary, dermatological, and severe neurological diseases. Over the past decades, numerous PDE4 inhibitors have been designed and synthesized, among which roflumilast, apremilast, and crisaborole were approved for the treatment of inflammatory airway diseases, psoriatic arthritis, and atopic dermatitis, respectively. It is regrettable that the dramatic efficacies of a drug are often accompanied by adverse effects, such as nausea, emesis, and gastrointestinal reactions. However, substantial advances have been made to mitigate the adverse effects and obtain better benefit-to-risk ratio. This review highlights the dialectical role of PDE4 in drug discovery and the disquisitive details of certain PDE4 inhibitors to provide an overview of the topics that still need to be addressed in the future.

Biologics and Small Molecule Agents in Allergic and Immunologic Skin Diseases

PURPOSE OF REVIEW

Biologics and small molecules are key therapeutic options in the treatment of chronic immunologic and allergic skin conditions. By directly targeting innate and inflammatory responses within the skin, including pro-inflammatory cytokines and cellular signaling pathways, these new agents have the potential to counteract the inflammatory cascade responsible for various conditions, including psoriasis and atopic dermatitis. Over the past decade, groundbreaking research identifying key cytokines and receptors involved in the pathogenesis of these diseases has allowed for the development of highly efficacious biologics and small molecules that are associated with unprecedented rates of skin clearance and favorable adverse event profiles.

RECENT FINDINGS

This narrative review evaluates new and upcoming biologic and small molecule agents for the treatment of two allergic/immunologic skin diseases-atopic dermatitis and psoriasis. Numerous small molecules and biologics targeting TNF-α, IL-12/23, IL-17 and IL-17R, and IL-23 are commercially available for the treatment of psoriasis, and newer agents are in various stages of development. Currently, dupilumab, a monoclonal antibody that blocks IL-4R∝, is the only approved biologic for atopic dermatitis. Antibodies targeting IL-13 and IL-31 and small molecules that inhibit Janus kinase and pruritus-mediating receptors are currently being studied in clinical trials. Further investigations into the pathophysiology of atopic dermatitis will likely yield additional therapeutic options in the future. This article reviews recent literature on small molecules and biologics for the treatment of atopic dermatitis and psoriasis.

Apremilast Ameliorates Experimental Arthritis via Suppression of Th1 and Th17 Cells and Enhancement of CD4+Foxp3+ Regulatory T Cells Differentiation

Apremilast is a novel phosphodiesterase 4 (PDE4) inhibitor suppressing immune and inflammatory responses. We assessed the anti-inflammatory effects of Apremilast in type II collagen (CII)-induced arthritis (CIA) mouse model. To determine whether Apremilast can ameliorate arthritis onset in this model, Apremilast was given orally at day 14 after CII immunization. Bone erosion was measured by histological and micro-computed tomographic analysis. Anti-mouse CII antibody levels were measured by enzyme-linked immunosorbent assay, and Th17, Th1 cells, and CD4⁺Foxp3⁺ regulatory T (Treg) cells were assessed by flow cytometry in the lymph nodes. Human cartilage and rheumatoid arthritis (RA) synovial fibroblasts (RASFs) implantation in the severe combined immunodeficiency mouse model of RA were used to study the role of Apremilast in the suppression of RASF-mediated cartilage destruction in vivo. Compared with untreated and vehicle control groups, we found that Apremilast therapy delayed arthritis onset and reduced arthritis scores in the CIA model. Total serum IgG, IgG1, IgG2a, and IgG2b were all decreased in the Apremilast treatment groups. Moreover, Apremilast markedly prevented the development of bone erosions in CIA mice by CT analysis. Furthermore, in the Apremilast treated group, the frequency of Th17 cells and Th1 cells was significantly decreased while Treg cells’ frequency was significantly increased. The high dose of Apremilast (25 mg/kg) was superior to low dose (5 mg/kg) in treating CIA. Apremilast treatment reduced the migratory ability of RASFs and their destructive effect on cartilage. Compared with the model group, Apremilast treatment significantly reduced the RASFs invasion cartilage scores in both primary implant and contralateral implant models. Our data suggest that Apremilast is effective in treating autoimmune arthritis and preventing the bone erosion in the CIA model, implicating its therapeutic potential in patients with RA.

The Interleukin-23/Interleukin-17 Axis Links Adaptive and Innate Immunity in Psoriasis

Research into the pathophysiology of psoriasis has shed light onto many fascinating immunological interactions and underlying genetic constellations. Most prominent among these is the crosstalk between components of the innate and the adaptive immune system and the crucial role of interleukins (IL)-23 and -17 within this network. While it is clear that IL-23 drives and maintains the differentiation of Th17 lymphocytes, many aspects of the regulation of IL-23 and IL-17 are not quite as straightforward and have been unraveled only recently. For example, we know now that Th17 cells are not the only source of IL-17 but that cells of the innate immune system also produce considerable amounts of this central effector cytokine. In addition, there is IL-23-independent production of IL-17. Besides other innate immune cells, neutrophilic granulocytes prominently contribute to IL-17-related immune regulations in psoriasis, and it appears that they employ several mechanisms including the formation of neutrophil extracellular traps. Here, we strive to put the central role of the IL-23/IL-17 axis into perspective within the crosstalk between components of the innate and the adaptive immune system. Our aim is to better understand the complex immune regulation in psoriasis, a disorder that has become a model disease for chronic inflammation.

Review article: novel oral-targeted therapies in inflammatory bowel disease

BACKGROUND

There is a great unmet clinical need for efficacious, tolerable, economical and orally administrated drugs for the treatment of inflammatory bowel disease (IBD). New therapeutic avenues have become possible including the development of medications that target specific genetic pathways found to be relevant in other immune mediated diseases.

AIMS

To provide an overview of recent clinical trials for new generation oral targeted medications that may have a future role in IBD management.

METHODS

Pubmed and Medline searches were performed up to 1 March 2018 using keywords: "IBD", "UC", "CD", "inflammatory bowel disease" "ulcerative colitis", "Crohn's disease" in combination with "phase", "study", "trial" and "oral". A manual search of the clinical trial register, article reference lists, abstracts from meetings of Digestive Disease Week, United European Gastroenterology Week and ECCO congress were also conducted.

RESULTS

In randomised controlled trials primary efficacy endpoints were met for tofacitinib (JAK 1/3 inhibitor-phase III), upadacitinib (JAK 1 inhibitor-phase II) and AJM300 (α4-integrin antagonist-phase II) in ulcerative colitis. Ozanimod (S1P receptor agonist-phase II) also demonstrated clinical remission. For Crohn's disease, filgotinib (JAK1 inhibitor-phase II) met primary endpoints and laquinimod (quinolone-3-carboxide small molecule-phase II) was also efficacious. Trials using mongersen (SMAD7 inhibitor) and vidofludimus (dihydroorotate dehydrogenase inhibitor) have been halted.

CONCLUSIONS

This is potentially the start of an exciting new era in which multiple therapeutic options are at the disposal of physicians to treat IBD on an individualised basis. Head-to-head studies with existing treatments and longer term safety data are needed for this to be possible.

Early and sustained efficacy with apremilast monotherapy in biological-naïve patients with psoriatic arthritis: a phase IIIB, randomised controlled trial (ACTIVE)

OBJECTIVE

Evaluate apremilast efficacy across various psoriatic arthritis (PsA) manifestations beginning at week 2 in biological-naïve patients with PsA.

METHODS

Patients were randomised (1:1) to apremilast 30 mg twice daily or placebo. At week 16, patients whose swollen and tender joint counts had not improved by ≥10% were eligible for early escape. At week 24, all patients received apremilast through week 52.

RESULTS

Among 219 randomised patients (apremilast: n=110; placebo: n=109), a significantly greater American College of Rheumatology 20 response at week 16 (primary outcome) was observed with apremilast versus placebo (38.2% (42/110) vs 20.2% (22/109); P=0.004); response rates at week 2 (first assessment) were 16.4% (18/110) versus 6.4% (7/109) (P=0.025). Improvements in other efficacy outcomes, including 28-joint count Disease Activity Score (DAS-28) using C reactive protein (CRP), swollen joint count, Health Assessment Questionnaire-Disability Index (HAQ-DI), enthesitis and morning stiffness severity, were observed with apremilast at week 2. At week 16, apremilast significantly reduced PsA disease activity versus placebo, with changes in DAS-28 (CRP) (P<0.0001), HAQ-DI (P=0.023) and Gladman Enthesitis Index (P=0.001). Improvements were maintained with continued treatment through week 52. Over 52 weeks, apremilast's safety profile was consistent with prior phase 3 studies in psoriasis and PsA. During weeks 0-24, the incidence of protocol-defined diarrhoea was 11.0% (apremilast) and 8.3% (placebo); serious adverse event rates were 2.8% (apremilast) and 4.6% (placebo).

CONCLUSIONS

In biological-naïve patients with PsA, onset of effect with apremilast was observed at week 2 and continued through week 52. The safety profile was consistent with previous reports.

TRIAL REGISTRATION NUMBER

NCT01925768; Results.

Successful treatment of SAPHO syndrome with apremilast

SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome is a rare disease with inflammatory osteoarticular and skin involvement. The pathogenesis of SAPHO syndrome remains unclear, but evidence suggests it may be an autoinflammatory disease triggered upon exposure to infectious agents in genetically predisposed individuals. Induction of the interleukin (IL)-23/T helper 17 axis in addition to neutrophil activation seem to play a key role, and therapies targeting these immunological pathways, including tumour necrosis factor (TNF) inhibitors, ustekinumab, secukinumab and the IL-1 inhibitor anakinra, are potential treatment options that need further investigation. Here we report a case of a 24-year-old woman with SAPHO syndrome who presented at our clinic with palmoplantar pustulosis and sternoclavicular joint involvement. Previous treatments with topical steroids and keratolytics combined with nonsteroidal anti-inflammatory drugs, intravenous methylprednisolone, methotrexate and sulfasalazine had all failed to improve symptoms. Therapy with etanercept was not tolerated, and because of a previous demyelinating peripheral neuropathy, further treatment with TNF inhibitors was avoided. We initiated ustekinumab 45 mg, which improved skin manifestations but not joint pain. Dose escalation to 90 mg initially improved joint pain, but the dose had to be reduced to 45 mg again because of increased infections. During subsequent 45-mg ustekinumab treatment, joint pain exacerbated so we switched to adalimumab which caused an exacerbation of the disease, so we switched to secukinumab, which improved skin and joint symptoms significantly but was associated with a pustular hypersensitivity reaction. Finally, we began treatment with apremilast, a pan-cytokine approach, resulting in stabilization of the skin and joint symptoms without side-effects. To our knowledge, this is the first case report of apremilast as a treatment for SAPHO syndrome.

East Indian Sandalwood Oil Is a Phosphodiesterase Inhibitor: A New Therapeutic Option in the Treatment of Inflammatory Skin Disease

Cyclic adenosine monophosphate phosphodiesterases (PDEs) regulate pro-inflammatory cytokine production. One isoform, PDE4, is overactive in chronic relapsing inflammatory skin diseases: psoriasis and eczema/atopic dermatitis, and in several cancers. East Indian sandalwood oil (EISO) has significant anti-inflammatory properties. Here, we report that 75% of pediatric eczema/atopic dermatitis patients treated with topical EISO formulations achieved a >50% reduction in their Eczema Area and Severity Index score. EISO treatment of a psoriasis model reduced PDE4 expression and reversed histopathology. EISO directly inhibited PDE enzymatic activity in vitro. In lipopolysaccharide-stimulated human dermal fibroblast, BEAS-2B, A549, and THP-1 cells, EISO suppressed total cellular PDE activity, PDE4, and 7 transcript levels, nuclear factor kappa B (NF-κB) activation, and pro-inflammatory cytokines/chemokine production. These results suggest that EISO anti-inflammatory activity is mediated through suppressing PDE activity, thus facilitating cAMP-regulated inhibition of NF-κB and indicate EISO as an attractive natural therapeutic for chronic and acute inflammatory disorders.

Integration of machine learning and meta-analysis identifies the transcriptomic bio-signature of mastitis disease in cattle

Gram-negative bacteria such as Escherichia coli (E. coli) are assumed to be among the main agents that cause severe mastitis disease with clinical signs in dairy cattle. Rapid detection of this disease is so important in order to prevent transmission to other cows and helps to reduce inappropriate use of antibiotics. With the rapid progress in high-throughput technologies, and accumulation of various kinds of '-omics' data in public repositories, there is an opportunity to retrieve, integrate, and reanalyze these resources to improve the diagnosis and treatment of different diseases and to provide mechanistic insights into host resistance in an efficient way. Meta-analysis is a relatively inexpensive option with good potential to increase the statistical power and generalizability of single-study analysis. In the current meta-analysis research, six microarray-based studies that investigate the transcriptome profile of mammary gland tissue after induced mastitis by E. coli infection were used. This meta-analysis not only reinforced the findings in individual studies, but also several novel terms including responses to hypoxia, response to drug, anti-apoptosis and positive regulation of transcription from RNA polymerase II promoter enriched by up-regulated genes. Finally, in order to identify the small sets of genes that are sufficiently informative in E. coli mastitis, the differentially expressed gene introduced by meta-analysis were prioritized by using ten different attribute weighting algorithms. Twelve meta-genes were detected by the majority of attribute weighting algorithms (with weight above 0.7) as most informative genes including CXCL8 (IL8), NFKBIZ, HP, ZC3H12A, PDE4B, CASP4, CXCL2, CCL20, GRO1(CXCL1), CFB, S100A9, and S100A8. Interestingly, the results have been demonstrated that all of these genes are the key genes in the immune response, inflammation or mastitis. The Decision tree models efficiently discovered the best combination of the meta-genes as bio-signature and confirmed that some of the top-ranked genes -ZC3H12A, CXCL2, GRO, CFB- as biomarkers for E. coli mastitis (with the accuracy 83% in average). This research properly indicated that by combination of two novel data mining tools, meta-analysis and machine learning, increased power to detect most informative genes that can help to improve the diagnosis and treatment strategies for E. coli associated with mastitis in cattle.

Potential immunotherapies for sarcoidosis

INTRODUCTION

Sarcoidosis is a chronic granulomatous inflammatory disease that commonly causes lung disease, but can affect other vital organs and tissues. The cause of sarcoidosis is unknown, and current therapies are commonly limited by lack of efficacy, adverse side effects, and excessive cost.

AREAS COVERED

The manuscript will provide a review of current concepts relating to the pathogenesis of sarcoidosis, and how these disease mechanisms may be leveraged to develop more effective treatments for sarcoidosis. It provides only a brief summary of currently accepted therapy, while focusing more extensively on potential novel therapies.

EXPERT OPINION

Current sarcoidosis therapeutic agents primarily target the M1 or pro-inflammatory pathways. Agents that prevent M2 polarization, a regulatory phenotype favoring fibrosis, are attractive treatment alternatives that could potentially prevent fibrosis and associated life threatening complications. Effective treatment of sarcoidosis potentially requires simultaneous modulation both M1/M2 polarization instead of suppressing one pathway over the other to restore immune competent and inactive (M0) macrophages.

[Therapy of Psoriasis Arthritis Taking into Account New Treatment Options]

Therapy of Psoriasis Arthritis Taking into Account New Treatment Options Abstract. Psoriatic arthritis occurs in about 20-30 % of patients with psoriasis. The disease is heterogeneous and can involve a variety of the distinct anatomical sites. The choice of medication depends on the type and the severity of clinical features. The recommendations of EULAR and GRAPPA serve as a guide for the choice of medication, which is used in sequential treatment steps. This is presented in our review in usable, simplified terms. Potential comorbidities leading to contraindication for certain treatments are considered. We present new and highly effective treatments, based on the pathogenesis of psoriasis and psoriatic arthritis, targeting the IL-23/IL-17 pathway.

Management of Common Side Effects of Apremilast

Apremilast is a relatively new therapy for the treatment of moderate to severe plaque psoriasis in adults. While this medication is considered safe with a very low risk of serious side effects, a few common (≥5% of patients) mild to moderate side effects have been reported, including diarrhea, nausea, headache, and nasopharyngitis. Not addressing these symptoms may lead to medication nonadherence and unnecessary discontinuation of therapy. These side effects are often easily managed with interventions available to the practicing dermatologist, and in only rare instances will these side effects require dose adjustment or discontinuation of therapy. The purpose of this article is to review common side effects of apremilast at its approved dose of 30 mg orally twice daily (BID) and to provide clear, simple recommendations for their management in dermatological practice.

Comparative effectiveness of abatacept, apremilast, secukinumab and ustekinumab treatment of psoriatic arthritis: a systematic review and network meta-analysis

To assess the comparative effectiveness and safety of novel biologic therapies in psoriatic arthritis (PsA) and to establish the position of the non-anti-tumor necrosis factor α (TNF-α) biologic drugs in the treatment regimen of the disease. A systematic review and network meta-analysis (NMA) was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) requirements. Two investigators identified the studies, abstracted data, and assessed the risk of bias independently. The NMA was conducted for efficacy [American College of Rheumatology (ACR) criteria, ACR20 and ACR50; psoriasis area and severity index (PASI), PASI75] and safety outcomes [any adverse events (AEs) and serious adverse events (SAEs)]; treatments were ranked using the P score for each outcome. The PROSPERO registration number was 42017072200. MEDLINE/PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched from the inception of each database to July 10, 2017. Randomized controlled trials (RCTs) for abatacept, apremilast, secukinumab or ustekinumab in adults with moderate and severe PsA were included. The overall PsA population and anti-TNF-α-naive, anti-TNF-α-failure, or anti-TNF-α-experienced subpopulations were considered. We identified eight eligible RCTs and included them in the systematic review and NMA. Significant differences in ACR20 response rate were revealed between secukinumab 150 mg and apremilast 20 mg [relative risk; RR = 2.55 (CI-confidence interval; 1.24, 5.23)] and between secukinumab 300 mg and apremilast 20 or 30 mg [RR = 3.57 CI (1.48, 8.64) and RR = 2.84 CI (1.18, 6.86), respectively]. Any AEs occurred more often in apremilast 20 and 30 mg compared with placebo [RR = 0.58 CI (0.45, 0.74) and RR = 0.58 CI (0.45, 0.75), respectively] but also compared with secukinumab 150 mg [RR = 0.54 CI (0.35, 0.81) and RR = 0.45 CI (0.35, 0.82), respectively]. No significant differences were revealed for SAEs among biologics and between biologics and placebo. In the overall population, as well as in the anti-TNF-α-naive subpopulation, secukinumab at a dose of 300 and 150 mg was ranked the highest for the ACR20 endpoint, while in the anti-TNF-α-experienced subpopulation, secukinumab 300 mg and apremilast 30 mg revealed the highest rank. Secukinumab 75 mg was the safest drug in terms of any AEs, but for SEAs the safest was ustekinumab 90 mg. Our study revealed no significant differences among non-anti-TNF-α biologics in the treatment of PsA in the comparisons performed with regards to the highest efficacy and safety. Both in the overall population and in the analyzed subpopulations, secukinumab 300 mg was ranked the highest for the ACR20 response rate. Secukinumab 300 mg was the safest drug in terms of any AEs, and ustekinumab 90 mg presented the lowest overall risk of SAEs. Head-to-head trials and evaluation of comparative efficacy and safety between non-TNF-α biologics are warranted to inform clinical decision making with a relevant treatment paradigm.

Rapid clearance of erythrodermic psoriasis with apremilast

Background

Apremilast is a new immunomodulatory drug, a small molecule inhibitor of PDE4, which down-regulates the expression of multiple pro-inflammatory cytokines, such as tumor necrosis factor alpha, interleukin 17, interleukin 23.

Main observations

We describe a case of a 54-year-old man with erythroderma in the course of psoriasis (PASI=49), with contraindications to other psoriasis therapies, in whom total clearance of skin lesions was achieved by day 20 after therapy with apremilast at a dose of 30 mg bid (ΔPASI = 100). The patient had a history of prior use of cyclosporine, methotrexate and adalimumab. His comorbidities included obesity, fatty liver and hypercholesterolemia.

Conclusion

In this case of erythroderma in the course of psoriasis apremilast led to total clearance of all cutaneous lesions.

Repigmentation of Tenacious Vitiligo on Apremilast

Vitiligo is a common pigment disorder characterized by acquired loss of function or absence of melanocytes, leading to distinct areas of depigmentation. Physical exam reveals sharply demarcated, depigmented macules or patches on otherwise normal skin. Vitiligo can present at any age, in any skin color. There is no specific serologic marker for diagnosis, but patients often have other autoimmune problems. Treatment options are limited and are difficult given the fact that the pathogenesis of the disease is not well elucidated. We present the case of a 52-year-old woman with vitiligo for over 2 decades. The patient's medical history reveals a lack of response to many different approaches. This case highlights the ability of apremilast, an FDA-approved drug for the treatment of psoriasis and psoriatic arthritis, to achieve repigmentation in a case a vitiligo that has been extremely recalcitrant.

Thalidomide and thalidomide analogues in treatment of patients with inflammatory bowel disease: Meta-analysis

AIM

To examine the efficacy and safety of thalidomide and thalidomide analogues in induction and maintenance of remission in patients with inflammatory bowel disease (IBD).

METHODS

A literature search was performed in the following databases: PubMed, EMBASE, Web of Science, Ovid and the Cochrane Library, and Chinese databases such as the China National Knowledge Infrastructure, China Science and Technology Journal Database (VIP), Wanfang Data. The randomized controlled analysis was performed to assess the effects of thalidomide therapy on inflammatory bowel disease for patients who did show good response with other therapies.

RESULTS

Three studies (n = 212) met the inclusion criteria were used in this Meta-analysis. No difference was found between thalidomide/thalidomide analogues and placebo in the induction of remission (RR = 1.36, 95%CI: 0.83-2.22, P = 0.22), the induction of clinical response (RR = 1.14, 95%CI: 0.75-1.72, P = 0.54) and the induction of adverse events (RR = 1.41, 95%CI: 0.99-2.02, P = 0.06).

CONCLUSION

Currently, there is not enough evidence to support use of thalidomide or its analogue for the treatment in patients of any age with IBD. However, it warrants a reanalysis when more data become available.

Biological Therapeutic Treatment of Atopic Dermatitis

Atopic dermatitis is a chronic recurrent inflammatory disease caused, inter alia, by violations of the barrier function of the skin and pathological immune response in the form of an imbalance of Th1 and Th2 lymphocytes with increased production of IL-4, IL-5, IL-13, IL-31. Treatment of severe forms of atopic dermatitis is not an easy task due to the variability of the individual response to treatment, the short duration of the therapeutic effect and the frequent development of undesirable phenomena associated with the use of existing methods of systemic immunosuppressive therapy. The study of the pathogenesis of atopic dermatitis made it possible to identify the spectrum of molecular targets, providing the basis for researching alternative variants to the previously used systemic therapy methods – genetic engineering biological preparations. Contemporary data on the pathogenesis of atopic dermatitis as well as potential molecular targets for innovative biological preparations, the efficacy of which has been evaluated through clinical trials, are presented in the review. 

Signaling Рathway Blockers: Action Mechanism, Efficacy, Safety of Therapy for Patients with Psoriasis and Psoriatic Arthritis

In the literature review, contemporary data on immune pathogenesis of psoriasis and the emergence of comorbid states against the background of systemic chronic inflammation among patients is discussed. On the example of the apremilast medical preparation, the information on a new class of therapeutic agents for the treatment of psoriasis and psoriatic arthritis – “small molecules” is given, including their physicochemical properties and action mechanism, as well as on the key differences from immune-suppressive and genetically engineered biological preparations. Data on large-scale international randomised clinical trials of the efficacy and safety of the PDE4 inhibitor of apremilast among patients with moderate to severe psoriasis and psoriatic arthritis is presented. The published international clinical recommendations on the use of apremilast among patients with psoriasis and psoriatic arthritis, the criteria for evaluating the response to therapy, as well as the potential profile of patients for the use of apremilast in real clinical practice are discussed.

Small molecule therapy for managing moderate to severe psoriatic arthritis

INTRODUCTION

The majority of psoriatic arthritis (PsA) patients experience a good clinical response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologic therapies (bDMARDs). However, treatment failure with these drugs can represent a relevant clinical problem. Moreover, in daily clinical practice, the appropriate identification of patients eligible for these agents can be conditioned by numerous aspects, mainly represented by comorbidities, such as history of malignancies, chronic and recurrent infectious diseases. Areas covered: We searched in the PUBMED database and review published data on the efficacy and safety profile of the small molecules, inhibitor of phosphodiesterase 4, apremilast, and of JAK/STAT pathways, tofacitinib, in PsA. Moreover, we report data on the other JAK inhibitor, baricitinib, and the A(3) adenosine receptors agonist, CF101, emerging by studies conducted in psoriasis patients. Expert opinion: In Psoriatic Arthritis, apremilast appears promising for PsA and recent studies have shown a good efficacy and an acceptable safety profile. Data on tofacitinib in PsA are limited. Studies on the small molecules, baricitinib and CF101 are still incomplete and limited to trials conducted in Rheumatoid Arthritis and in psoriasis. Further studies on small molecules and on their underlining mechanisms are advocated in PsA.