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Low drug-drug interaction makes acitretin attractive in psoriasis Tx

Montreal, QC -- Used on its own to treat pustular psoriasis, or in combination with phototherapy to treat plaque-type psoriasis, acitretin (Soriatane(tm), Roche) is very effective and fast-acting, said John Koo, MD, Professor and Vice-chairman, Department of Dermatology, University of California, San Francisco.

In his practice, he uses acitretin more than methotrexate or cyclosporine in both treatment and maintenance of the disease, Dr. Koo said at Dermatology Update 2003. "In low doses (25 mg/day) it works like a primer. One of the best things about it is the low rate of drug-drug interaction," he said.

"Turtle-stacking" is sequential therapy that Dr. Koo has advocated for years. For a quick fix, he starts with a high dose of cyclosporine (4 to 5 mg/kg/day) (the "rabbit") and then tapers it, overlapping with acitretin (the slower-acting "turtle") to prevent flare-ups during transition to the lower dose. Acitretin or PUVA can then be used in maintenance of the disease, although PUVA may infer a small risk of melanoma, he said.

In terms of rotational therapy, he said he cannot imagine anyone going back on cyclosporine or methotrexate if they are doing well on acitretin, phototherapy, or a combination. Asked how to start a patient on acitretin who is currently on phototherapy, Dr. Koo said he would add 25 mg/day acitretin, then drop the dose of light in half within one week because the skin will burn easily when the scales start coming off.

Comparing acitretin to the new biological immunomodulators coming to the market this year, he said acitretin is just as effective (and in some cases more effective), and costs less. However, in the United States, many dermatologists are afraid to use acitretin, a retinoid, and biological immunomodulators are becoming more popular because they make the physician feel safer. "In Canada where people are not so extraordinarily fearful, they have good results with acitretin," Dr. Koo said. Patients taking acitretin may require anti-lipid medication.

This lecture, delivered at Dermatology Update 2003, was sponsored by Roche Canada, manufacturer of Soriatane.