For psoriasis with hepatitis, biologics are key

Internal Medicine News, Sept 15, 2008 by Sharon Worcester

DESTIN, FLA. -- Treating psoriasis in patients with hepatitis can pose a particular challenge, but good outcomes can be achieved with systemic treatment using appropriate agents, Dr. Jeffrey Sobell said.

Dr. Sobell described a patient with hepatitis C infection, long-standing psoriasis, and severe psoriasis flare who was being treated with interferon and ribavirin therapy for the hepatitis; therefore, topical and phototherapy for the psoriasis were not options.

Although an agent such as acitretin is not immunosuppressive, it is very slow acting and is associated with potential hepatotoxicity, as is methotrexate, the preferred agent for treating psoriasis. And cyclosporin, which can be a "great drug for patients in crisis" is broadly immunosuppressive, said Dr. Sobell of Tufts University, Boston.

"Essentially this leaves us with biologic agents," he said at a meeting sponsored by the Alabama Dermatology Society.

A number of case reports indicate that etanercept can be used successfully in hepatitis C patients, suggesting that this treatment would be beneficial in psoriasis patients who also have hepatitis C, according to Dr. Sobell.

In a phase II trial of 50 patients randomized to receive treatment with etanercept (25 mg, biweekly) or placebo, along with ribavirin and interferon, those in the etanercept/ribavirin/interferon group had significantly improved viral response and decreased side effects from the ribavirin and interferon. HCV RNA was absent in 12 of 19 (63%) patients in the treatment group, compared with 8 of 25 (32%) in the placebo group (J. Hep. 2005;42:315-22).

Adalimumab also has been used in the setting of hepatitis C; case reports suggest there is no reactivation of hepatitis C or change in viral load with the drug. Similarly, case reports involving treatment with infliximab in hepatitis C patients show no reactivation and no increase in liver function tests, he noted.

Case reports involving the anti-T cell agents efalizumab and alefacept in the setting of hepatitis C are less common. There have been no reports regarding efalizumab, and only two case reports on alefacept, with neither patient experiencing reactivation or increases in liver function test levels, Dr. Sobell said.

"If we look at hepatitis B, it's a completely different story," he said. There have been reports of hepatitis B activation with all three anti-TNF agents (etanercept, infliximab, and adalimumab), which in rare cases has led to liver failure and death.

This is very uncommon--the rate of hepatitis B reactivation is less than 1 in 10,000 with these agents, according to the literature, Dr. Sobell said, but there is a related warning involved with all three.

There are no case reports of using efalizumab for psoriasis patients with hepatitis B or hepatitis C, although Dr. Sobell said he has used anti-T cell agents with success in patients with psoriasis and hepatitis B.

There have been no case reports of hepatitis B exacerbation with acitretin; in fact, Dr. Sobell said he believes that the liver toxicity associated with acitretin has been overstated, and that those cases have involved doses that were higher than the recommended limits.

In addition, there is some evidence of improvement of hepatitis B in posttransplant patients who are treated with cyclosporine and interferon.

For the treatment of a patient with hepatitis C and psoriasis, Dr. Sobell said that it is important to work in conjunction with the patient's GI specialist. He advised considering treating with one of the anti-TNF agents. For hepatitis B chronic carriers, anti-TNF agents should be avoided, and caution should be used when treating with other hepatoxic drugs such as methotrexate and acitretin, he said.

Dr. Sobell disclosed that he is a consultant, speaker, and researcher for Genentech, Abbott Laboratories, and Centocor; he also has been a consultant and speaker for Amgen Inc.

BY SHARON WORCESTER Southeast Bureau