755982

research-article2018
CMSXXX10.1177/1203475418755982Journal of Cutaneous Medicine and SurgeryIghani et al

Original Article

Journal of Cutaneous Medicine and Surgery

1–7
Efficacy and Safety of Apremilast © The Author(s) 2018
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DOI: 10.1177/1203475418755982
https://doi.org/10.1177/1203475418755982

Psoriasis: Retrospective Study jcms.sagepub.com

Arvin Ighani1 , Jorge R. Georgakopoulos2, Linda L. Zhou3,

Scott Walsh4, Neil Shear4 , and Jensen Yeung4

Abstract
Background: Apremilast is a new oral drug for the treatment of moderate to severe plaque psoriasis that reduces
inflammation by inhibiting phosphodiesterase 4. Its efficacy and safety data are limited; hence, real-world outcomes are
important for elucidating the full spectrum of its adverse events (AEs) and expanding generalizability of clinical trial findings.
Objective: Assess the efficacy and safety of apremilast monotherapy in real-world practice.
Methods: A retrospective chart review was conducted in 2 academic dermatology practices. Efficacy was measured as the
proportion of patients achieving a ≥75% reduction from baseline Psoriasis Area and Severity Index score (PASI-75) or a
Psoriasis Global Assessment (PGA) score of 0 (clear) or 1 (almost clear) at 16 weeks. Safety was measured as the proportion
of patients reporting ≥1 AE at 16 weeks.
Results: Thirty-four patients were included. Efficacy: 19 patients (55.9%) achieved PASI-75 or PGA 0/1. Safety: 23 patients
(67.6%) experienced ≥1 AEs. Five patients (14.7%) withdrew treatment prior to week 16 due to AEs. One patient withdrew
treatment due to mood lability and depression. Common AEs included headache (32.4%), nausea (20.6%), diarrhoea (14.7%),
weight loss (8.8%), and loose stool (8.8%).
Conclusion: Apremilast monotherapy had higher efficacy with similar safety outcomes in the real world compared to clinical
trials. There were higher proportions of reported headaches compared to clinical trials. This study supports the apremilast
monotherapy clinical trial findings, suggesting that it has an acceptable safety profile and significantly reduces the severity of
moderate to severe plaque psoriasis. Limitations include the retrospective nature of the study.

Keywords
apremilast, monotherapy, plaque psoriasis, phosphodiesterase inhibitor, clinical practice

Psoriasis is a chronic, autoinflammatory skin condition with
a worldwide prevalence of 0.9% to 8.5% in adults and one of
the most frequently encountered skin diseases in clinical
practice.1,2 Numerous subtypes of psoriasis exist, with the
most common being plaque psoriasis.3 Psoriasis is strongly
associated with psychological morbidity and a low quality of
life, with almost one-fourth of patients identifying it as hav-
ing a significant negative impact on their lives.4,5
There is no cure for psoriasis, but therapies exist to reduce
its signs and symptoms, including topical agents, nonbiologic
systemic agents, phototherapy, and biologic agents.6-8
However, these therapies have shortcomings that limit patient
treatment options. For instance, approved conventional sys-
temic therapies like methotrexate, acitretin, and cyclosporine
are associated with severe adverse events, including hepato-
toxicity, nephrotoxicity, and leukocytopenia.9-11 Often, 1 or
more of these systemic agents are prescribed to patients
before more advanced therapies, like biologic agents, are
reimbursed by private and public payers.
Biologic agents are undeniably efficacious in the treat-
ment of psoriasis.12 Nevertheless, 3 recent surveys demon-
strated that patients with moderate to severe plaque psoriasis
discontinued treatment with currently available biologics
and conventional systemic therapies due to overwhelming
monitoring regimens, fear of injections, inability to tolerate
their medications, and lack of efficacy.13-15 Hence there is a
need to develop novel therapeutic agents in the treatment of
1
Faculty of Medicine, University of Toronto, Toronto, ON, Canada
2
Schulich School of Medicine and Dentistry, Western University, London,
ON, Canada
3
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
4
Division of Dermatology, Department of Medicine, University of
Toronto, Toronto, ON, Canada
Corresponding Author:
Jensen Yeung, Department of Dermatology, Women’s College Hospital,
76 Grenville St, Fifth Floor, Toronto, ON M5S 1B2, Canada.
Email: jensen.yeung@utoronto.ca
2 Journal of Cutaneous Medicine and Surgery 00(0)
psoriasis that are efficacious, are safe, and address these
shortcomings.
Apremilast (tradename Otezla; Celgene Corporation,
Summit, New Jersey) is a novel oral agent that was approved
in November 2014 in Canada for the treatment of moderate to
severe plaque psoriasis. It is a phosphodiesterase 4 (PDE4)
inhibitor that modulates inflammatory signalling pathways
believed to play a central role in the development of the
disease.16 Two pivotal phase III clinical trials, ESTEEM 1
and ESTEEM 2, demonstrated that it had an acceptable safety
profile and significantly reduced the severity of moderate to
severe plaque psoriasis.17,18 Common adverse events reported
in the clinical trials were diarrhoea, upper respiratory tract
infection (URTI), nausea, nasopharyngitis, and headache.
However, analysis of this treatment in the real-world setting
as a monotherapy for moderate to severe plaque psoriasis is
limited, and there are very scant data on the topic of real-
world outcomes of apremilast. Furthermore, patient selection
in clinical trials is often biased toward healthy individuals and
does not reflect the general patient population in real-world
practice who may have comorbidities, including various can-
cers, psychiatric disease, and infections such as hepatitis C.
This study aims to analyse the safety and efficacy of apre-
milast in 2 real-world academic dermatology centres at the
University of Toronto to evaluate the generalizability of its
clinical trial results.
Patients and Methods
Study Design
A retrospective chart review was conducted on patients pre-
scribed apremilast at Sunnybrook Health Sciences Centre
(SHSC) and Women’s College Hospital (WCH), which are
affiliated with the University of Toronto in Toronto, Ontario,
Canada. Data collection was undertaken between May 2016
and September 2016 following research ethics board
approval and completion of a data transfer agreement at both
SHSC and WCH.
Patients 18 years or older receiving at least 16 weeks of
apremilast monotherapy for the treatment of moderate to
severe plaque psoriasis were included in this study. Patients
who withdrew treatment prior to week 16 due to an adverse
event or lack of efficacy were also included, but they were
considered nonresponders. Monotherapy was defined as
usage of apremilast without any concurrent systemic treat-
ment for their psoriasis. Patients were permitted to use topi-
cal agents with their apremilast treatment.
Efficacy
The primary efficacy end point was the proportion of patients
achieving at least 75% improvement in their Psoriasis Area
and Severity Index score (PASI-75) or a Psoriasis Global
Assessment (PGA) score of 0 (clear) or 1 (almost clear) at
week 16 of treatment. The PGA was ranked using a 6-point
Likert scale, ranging from 0 to 5, with higher scores reflect-
ing more significant psoriasis. In instances where PASI-75 or
PGA scores were not documented, 2 independent reviewers
assigned PGA scores based on the chart description of pso-
riasis lesions.
Safety
The primary outcome for assessing the safety of apremilast
was the proportion of patients experiencing 1 or more
adverse events during the first 16 weeks of treatment. The
secondary outcome for assessing safety was the proportion
of patients who discontinued apremilast due to adverse
events prior to week 16. A serious adverse event was
defined as any event that was life-threatening, was fatal,
required hospitalization, or resulted in a persistent or sig-
nificant lack of function, capacity, or other medical hazard.
Otherwise, the adverse event was considered mild to mod-
erate. All adverse events listed in the patient chart were
recorded.
Data Analysis
Descriptive statistics were conducted to summarize efficacy
and safety end points using SPSS Statistics for Macintosh,
version 23 (SPSS, Inc, an IBM Company, Chicago, Illinois).
Quantitative variables were analysed using means and stan-
dard deviations, and categorical variables were analysed
using frequencies and percentages. Binary logistic regres-
sion was conducted to assess the influence of variables on
the responder outcome of patients. P values ≤.05 were con-
sidered statistically significant.
Results
Population Demographics
Fifty-two patients were screened and prescribed 30 mg of
oral apremilast twice daily after graduated introductory
dosing (0/10, 10/10, 20/10, 20/20, and 30/20) over 5 days
and then 30/30 dosing as per the product monograph.
Follow-up visits were scheduled for approximately 4
months after the initial dose was prescribed. Patients were
followed up as needed in instances where adverse events
were reported.
Of the 52 patients screened, 34 were included in the study
(Figure 1). Eighteen patients were excluded from the analy-
sis: 11 with no follow-up data, 3 lacking PGA or PASI-75
score documentation, 3 not having plaque psoriasis, and 1
who was clear of psoriasis at baseline. There were no cases
of dose changes or restarts in the 34 patients included for
analysis.
Ighani et al
Figure 1. Flowchart depicting the screening and selection process of the study cohort based on inclusion criteria.
The cohort had a mean age of 53.5 ± 12.7 years at the
start of treatment and comprised 20 men (58.8%) and 14
women (41.2%) (Table 1). The mean disease duration prior
to the first apremilast dose was 20 ± 13.5 years. Common
comorbidities in this cohort included arthritis (32.4%),
hypertension (17.6%), dyslipidemia (17.6%), and fatty liver
disease (14.7%). The most commonly failed therapies prior
to apremilast treatment included phototherapy (67.6%),
methotrexate (47.1%), and acitretin (35.3%). On average,
patients failed 1.7 ± 1.3 nontopical therapies before starting
apremilast.
Efficacy
Of the 34 patients analysed, 19 (55.9%) achieved PASI-75 or
a PGA of 0 or 1 at week 16 (Table 2). One patient (2.9%)
withdrew treatment before the 16-week period due to lack of
efficacy. The mean PASI-75 score was 13.1 ± 6.3 at baseline
(collected from n = 18) and 3.9 ± 5.4 after 16 weeks of treat-
ment (collected from n = 8).
Binary logistic regression determined that none of the
variables analysed were statistically significant predictors of
treatment response, including sex (P = .901) and age (P =
.726). However, the number of previously failed nontopical
therapies (P = .067) and comorbid fatty liver disease (P =
.080) trended inversely with response outcome.
3
Safety
Of the 34 patients analysed, 23 (67.6%) reported 1 or more
adverse events (Table 2). A total of 5 patients (14.7%) with-
drew treatment due to adverse events: headaches (n = 1),
diarrhoea (n = 1), mood lability with depression (n = 1), nau-
sea with loose stool (n = 1), and a combination of headaches,
dizziness, nausea, vomiting, and diarrhoea (n = 1).
The most frequent adverse events included headache (n =
11, 32.4%), nausea (n = 7, 20.6%), diarrhoea (n = 5, 14.7%),
weight loss (n = 3, 8.8%), and loose stool (n = 3, 8.8%) (Table
2). Some patients reported more than 1 adverse event, with an
average of 1.5 ± 1.5 adverse events reported per patient. No
serious or severe adverse events were reported. There was 1
incidence of depression (2.9%), and this patient discontinued
treatment. It was unclear if this patient had a prior history of
depressive symptoms prior to starting apremilast.
Discussion
We report the findings of a retrospective study evaluating the
efficacy and safety of apremilast monotherapy in the treatment
of 34 patients with moderate to severe plaque psoriasis at 2
academic clinics in Toronto, Ontario, Canada. In this cohort,
55.9% of patients responded to treatment, achieving clinically
significant clearance of psoriasis following 16 weeks of
4 Journal of Cutaneous Medicine and Surgery 00(0)

Table 1. Population Demographics and Characteristics of the Table 2. Efficacy and Safety Outcomes (n = 34).
Study Cohort (n = 34).
Variable Value
Variable Value P Value
Efficacy end point, No. (%)
Sex, No. (%) .901 PASI-75 or PGA 0/1 at week 16 19/34 (55.9)
Male 20/34 (58.8) Baseline PASI-75, mean ± SD 13.1 ± 6.3
Female 14/34 (41.2) 16-week PASI-75, mean ± SD 3.9 ± 5.4
Age, mean ± SD, y .726 Safety end point, No. (%)
Mean age 53.5 ± 12.7 ≥1 AEs 23 (67.6)
Age at time of diagnosis 33.5 ± 15.3 Treatment withdrawal before 5 (14.7)
Disease duration, mean ± SD, y 20 ± 13.5 week 16 due to AE, No. (%)
Comorbidities, No. (%) Headache 1 (2.9)
Arthritis 11 (32.4) .336 Diarrhoea 1 (2.9)
Hypertension 6 (17.6) .136 Mood lability, depression 1 (2.9)
Dyslipidemia 6 (17.6) .749 Nausea, loose stool 1 (2.9)
Fatty liver disease 5 (14.7) .080 Headache, dizziness, nausea, 1 (2.9)
Renal disease 3 (8.8) .410 vomiting, diarrhoea
Diabetes 3 (8.8) .410 Reported AEs, No. (%)
Depression 3 (8.8) .694 Headache 11 (32.4)
Fibromyalgia 3 (8.8) .410 Nausea 7 (20.6)
Gastroesophageal reflux 3 (8.8) .694 Diarrhoea 5 (14.7)
disease Weight loss 3 (8.8)
Hypothyroidism 3 (8.8) .410 Loose stool 3 (8.8)
Anaemia 2 (5.9) .101 Dizziness 2 (5.9)
Back pain 2 (5.9) .101 Abdominal pain 2 (5.9)
Hepatitis C 2 (5.9) .195 Arthralgia 2 (5.9)
Breast cancer history 2 (5.9) .863 Vomiting 1 (2.9)
Psychiatric disorders 2 (5.9) .195 Sunburn 1 (2.9)
(unspecified) Palpitations 1 (2.9)
Previously failed nontopical .067 Mood lability 1 (2.9)
therapies, No. (%) Migraine 1 (2.9)
0 3 (8.8) Iritis 1 (2.9)
1 15 (44.1) Insomnia 1 (2.9)
2 11 (32.4) Increased bowel movements 1 (2.9)
3 1 (2.9) Gastrointestinal upset 1 (2.9)
≥4 4 (11.8) Flatulence 1 (2.9)
Number of previously failed 1.7 ± 1.3 Disturbed sleep 1 (2.9)
therapies, mean ± SD Disorientation 1 (2.9)
Failed therapies prior to apremilast first dose, No. (%) Depression 1 (2.9)
Phototherapy 23 (67.6) Blurred vision 1 (2.9)
Methotrexate 16 (47.1) Bloating 1 (2.9)
Acitretin 12 (35.3) Back pain 1 (2.9)
Etanercept 3 (8.8) Reported AEs per patient, No. (%)
Infliximab 3 (8.8) 0 11 (32.4)
Cyclosporine 1 (2.9) 1 10 (29.4)
Adalimumab 1 (2.9) 2 5 (14.7)
Prior systemic therapy 22 (64.7) 3 3 (8.8)
(conventional and/or ≥4 5 (14.7)
biologics), No. (%)
Mean ± SD 1.5 ± 1.5
Prior conventional systemic 21 (61.8)
therapy, No. (%) Abbreviations: AE, adverse event; PASI-75, ≥75% reduction from baseline
Prior biologic therapy, No. (%) 4 (11.8) Psoriasis Area and Severity Index score (PASI-75); PGA, Psoriasis Global
Assessment; SD, standard deviation.
Abbreviation: SD, standard deviation.

due to adverse events during the first 16 weeks of treatment.

treatment. A total of 67.6% of patients reported 1 or more Overall, these findings support the results of the landmark
adverse events, and 14.7% of patients withdrew apremilast phase III ESTEEM clinical trials on apremilast, suggesting
Ighani et al
that it has an acceptable safety profile and significantly reduces
the severity of moderate to severe plaque psoriasis over 16
weeks.17,18
In terms of population demographics, the mean age of
patients in our study (53.5 ± 12.7 years) was greater than
ESTEEM 1 (45.8 ± 13.1 years) and ESTEEM 2 (45.3 ± 13.1
years), and the proportion of males in our study (58.8%) was
lower than in clinical trials (64.2%-67.4%).17,18 At the outset
of apremilast therapy, the mean baseline PASI-75 score of
our cohort (13.1 ± 6.3) was also lower compared to those
seen in ESTEEM 1 (18.7 ± 7.2) and ESTEEM 2 (18.9 ± 7.1).
The use of prior systemic and biologic therapies in our study
varied greatly compared to the clinical trials. While 11.8% of
our patients previously used biologic therapy, 28.8% to
33.6% of patients in the clinical trials previously failed using
biologics. Conversely, 61.8% of our patients had prior con-
ventional systemic therapy compared to only 37.7% to 38.7%
in clinical trials.
When comparing efficacy, this study reports 55.9% of
patients as responders, whereas the ESTEEM trials reported
between 28.8% and 33.1% as responders.17,18 The greater
proportion of responders in this study may partly be a result
of patients being permitted to use any grade of topical ther-
apy at any point in their apremilast therapy to treat their pso-
riasis. This is in contrast to the ESTEEM clinical trials in
which patients were restricted in terms of their use of topical
therapies; choice of topical corticosteroids was limited to
weak or low-potency strength (class 6 or 7), and they were
not permitted to be applied within 24 hours of a clinic
visit.17,18 In addition, this study defined the primary outcome
of clinically significant clearance as PASI-75 or PGA 0 or 1,
whereas the ESTEEM clinical trials adhered to a more strin-
gent primary outcome of PASI-75 response. This might have
contributed to a greater number of patients identified as
responders in this study compared to clinical trials.
Interestingly, the number of previously failed nontopical
therapies (P = .067) and comorbid fatty liver disease (P =
.080) trended inversely with response outcome.
In regards to safety, 67.6% of patients reported 1 or more
adverse events compared to 68.0% to 69.3% of patients in the
clinical trials. Many of the common adverse events reported
in this chart review, such as diarrhoea and nausea, were shown
in comparable proportions in the clinical trials. In this cohort,
20.6% reported nausea and 14.7% reported diarrhoea com-
pared to 15.7% to 18.4% and 15.8% to 18.8% in clinical trials
reporting nausea and diarrhoea, respectively.17,18 A total of
8.8% of patients also reported weight loss within 16 weeks in
our study. Weight loss is a well-known adverse event of apre-
milast in long-term 52-week therapy, but short-term 16-week
weight loss data were not reported in the clinical trials for
comparison.
Our results indicate that 32.4% of patients reported head-
aches compared to 5.5% to 6.3% reporting headaches and
7.3% to 7.4% reporting tension headaches in clinical trials.
Although headaches were broadly defined in this study, our
5
reported proportion far outweighs the sum of both headaches
and tension headaches in clinical trials. The higher propor-
tion in real-world practice could be due to patient recall bias
and subsequent overreporting. Patients were informed of
potential side effects prior to starting treatment, and it may
have influenced their adverse event reporting during follow-
up. There were no reports of nasopharyngitis or URTIs in our
cohort compared to 7.3% to 7.4% reporting nasopharyngitis
and 4.8% to 10.2% reporting URTIs in clinical trials.
Common adverse events such as URTI and nasopharyngitis
were not actively elicited or recorded in the academic clinics
of this study, and this may explain why there were no such
reports. No routine laboratory values were recorded in real-
world practice as monitoring is not indicated in the product
monograph.19
In terms of withdrawals, 14.7% of patients withdrew
treatment due to adverse events prior to 16 weeks, whereas
only 5.2% to 5.5% of patients in the clinical trials withdrew
in the same period. Clinical trial medication adherence is fre-
quently higher than real-world adherence and could explain
the higher proportion of withdrawals.20 This may be in part
because patients enrolled in clinical trials might lack insur-
ance coverage and do not have options to switch to alterna-
tive therapies. Furthermore, patients enrolled in clinical trials
may demonstrate higher medication adherence because of
more frequent clinical visits.21 Notably, there was 1 patient
who reported depression with mood lability while taking
apremilast and ultimately discontinued treatment. However,
we were uncertain whether this patient had symptoms of
depression prior to the start of apremilast. In ESTEEM 1 and
2, rates of depression were slightly higher in the treatment
group compared to the placebo group during the first 16
weeks of treatment.17,18
The LIBERATE study, a phase IIIb randomized con-
trolled trial, also measured apremilast outcomes at 16 weeks
but included only adult patients with chronic plaque psoria-
sis who had no prior exposure to biologic therapies (n =
83).22 Accordingly, the population demographics of this trial
resembled those of our real-world cohort, since few of our
patients (11.8%) had prior biologic exposure as well. Other
baseline demographics were comparable to our study, includ-
ing sex distribution (LIBERATE: 59.0% male; real world:
58.8% male) and baseline duration of psoriasis (LIBERATE:
19.7 ± 12.7 years; real world: 20.0 ± 13.5 years). In the
LIBERATE trial, 39.8% of patients achieved PASI-75 by
week 16, compared to 55.9% achieving PASI-75 or PGA 0/1
in our study. Like the ESTEEM trials, the higher proportion
of real-world response rates may be explained by our defini-
tion of a successful response, which encompassed both
PASI-75 and PGA 0/1 instead of PASI-75 alone.
In terms of safety, ≥1 adverse events were reported in
similar proportions of LIBERATE patients (71.1%) and real-
world patients (67.6%).22 Most adverse events (≥95%) were
mild to moderate in severity in the LIBERATE trial, and this
paralleled our real-world study, which had no reports of
6 Journal of Cutaneous Medicine and Surgery 00(0)
serious or severe adverse events. Common adverse events
were typically reported in greater proportions for our real-
world patients: headache (LIBERATE: 13.3%; real world:
32.4%), nausea (LIBERATE: 10.8%; real world: 20.6%),
and diarrhoea (LIBERATE: 10.8%; real world: 14.7%).
Although the LIBERATE study also reported URTI (7.2%)
and nasopharyngitis (4.8%) amongst their most frequent
adverse events, we had no such reports because these adverse
events were not actively elicited in our study. Expectedly, the
proportion of withdrawals due to adverse events was greater
in real-world practice (14.7%) compared to the LIBERATE
trial (3.6%).
Overall, our study is one of the very few to evaluate the
real-world safety and efficacy data of apremilast monother-
apy for plaque psoriasis. These findings complement a recent
retrospective review, performed by some of our coauthors,
that evaluated apremilast combination therapy with conven-
tional systemic and biologic agents and found clinically sig-
nificant improvement of plaque psoriasis in all therapeutic
subgroups.23 The results of this study have also been found to
be generally consistent with the results of another recent ret-
rospective review that evaluated the long-term use of apre-
milast therapy in various subtypes of psoriasis.24 In their
cohort of 81 patients, 37% of patients with ongoing apremi-
last treatment achieved a body surface area <1%, and 61.7%
of patients reported mild to moderate adverse events.
Interestingly, like our study, URTIs were less commonly
reported in their clinic compared to clinical trials.
Limitations include the small patient cohort, the inherent
retrospective nature of chart reviews that may predispose
internal bias, and the fact that data were originally recorded
for the purposes of clinical care as opposed to clinical
research. Given that this was a multicentre study, dermatolo-
gists at different centres subject their patients to diverse man-
agement strategies, and this may also play a role in differing
treatment outcomes. Finally, the study took place in Toronto,
Ontario, Canada, where drug formularies, insurance cover-
age, and access to medication like apremilast vary from other
regions in the world.
In conclusion, this multicentre cohort study complements
previous clinical trial findings and supports apremilast as an
efficacious and safe drug in the treatment of moderate to
severe plaque psoriasis. Apremilast may have increased effi-
cacy in clinical practice compared to pivotal trials, bearing in
mind the biases in this study that might have partly contrib-
uted to the increased efficacy rates. In addition, this study
demonstrated higher proportions of reported headaches com-
pared to clinical trials, while most other adverse events were
mild to moderate and reported in similar proportions. Future
studies should focus on capturing more patients and reporting
efficacy and adverse events beyond 16 weeks of treatment.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Jensen Yeung has been a speaker and/or consultant and/or
investigator for AbbVie, Allergan, Amgen, Astellas, Boehringer
Ingelheim, Celgene, Centocor, Coherus, Dermira, Forward,
Galderma, Janssen, Leo, Lilly, Medimmune, Merck, Novartis,
Pfizer, Regeneron, Roche, Sanofi-Genzyme, Sun Pharma, Takeda,
and Valeant. Neil Shear has been a consultant and/or speaker for
AbbVie, Actelion, Amgen, Celgene, Hospira, Janssen, Janssen
Biotech, Lilly, Novartis, Sanofi, Genzyme, and Takeda. Scott
Walsh has been a consultant for AbbVie, Amgen, Celgene, Janssen,
and Lilly. Jorge R. Georgakopoulos, Arvin Ighani, and Linda L.
Zhou have no conflicts of interest to declare.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: We
acknowledge the Canadian Association of Psoriasis Patients and the
Canadian Institutes of Health Research (Institute of Musculoskeletal
Health and Arthritis) for supporting this project.
ORCID iDs
Arvin Ighani https://orcid.org/0000-0002-2164-3609
Neil Shear https://orcid.org/0000-0001-9151-1145
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