Advances in treating psoriasis in the elderly with small molecule inhibitors

ABSTRACT

Introduction: Due to the chronic nature of psoriasis, the population of elderly psoriasis patients is increasing. However, many elderly psoriatic patients are not adequately treated because management is challenging as a result of comorbidities, polypharmacy, and progressive impairment of organ systems. Physicians may hesitate to use systemic or biologic agents in elderly psoriasis patients because of an increased risk of adverse events in this patient population. Small molecule medications are emerging as promising options for elderly patients with psoriasis and other inflammatory conditions.

Areas covered: Here we review the efficacy, safety and tolerability of small molecule inhibitors apremilast, tofacitinib, ruxolitinib, baricitinib, and peficitinib in the treatment of psoriasis, with focus on their use in the elderly population.

Expert opinion: Although small molecule inhibitors demonstrate efficacy in elderly patients with psoriasis, they will require larger head-to-head studies and post-marketing registries to evaluate their effectiveness and safety in specific patient populations. Apremilast, ruxolitinib, and peficitinib are effective agents with favorable side effect profiles; however, physicians should exercise caution when prescribing tofacitinib or baricitinib in elderly populations due to adverse events. The high cost of these drugs in the U.S. is likely to limit their use.

KEYWORDS:

• Psoriasis
• elderly
• small molecule inhibitors
• apremilast
• tofacitinib
• ruxolitinib

Article highlights

• Elderly patients with psoriasis can be difficult to treat due to the presence of comorbidities, polypharmacy, age-related organ impairment, and the limited data available pertaining to systemic treatments.

• The use of traditional systemic medications is restricted by renal and hepatic toxicities, while biologics may be limited by the patient comorbidities, increased risk of infections, cost, and method of administration.

• While small molecule inhibitors are promising new treatment options that offer few side effects, affordable cost, and easy administration, only apremilast is currently FDA approved for use in psoriasis patients.

• Apremilast, ruxolitinib, and peficitinib may have favorable side effect profiles in elderly patients, but the use of tofacitinib or baricitinib in elderly populations should be monitored due to adverse events such as increased risk of herpes zoster, abnormal lab values, and infections.

• Small molecule inhibitors may demonstrate efficacy in elderly patients with psoriasis, but larger head-to-head studies and post-marketing registries are required to evaluate long-term efficacy, safety, and tolerability in specific patient populations.

This box summarizes key points contained in the article.

Declaration of interest

S Feldman is a speaker for Janssen and Taro. He is a consultant and speaker for Galderma, Stiefel/GlaxoSmithKline, Abbott Labs, Leo Pharma Inc. S Feldman has received grants from Galderma, Janssen, Abbott Labs, Amgen, Stiefel/GlaxoSmithKline, Celgene and Anacor. He is a consultant for Amgen, Baxter, Caremark, Gerson Lehrman Group, Guidepoint Global, Hanall Pharmaceutical Co Ltd, Kikaku, Lilly, Merck & Co Inc, Merz Pharmaceuticals, Mylan, Novartis Pharmaceuticals, Pfizer Inc, Qurient, Suncare Research and Xenoport. He is on an advisory board for Pfizer Inc. S Feldman is the founder and holds stock in Causa Research and holds stock and is majority owner in Medical Quality Enhancement Corporation. He receives Royalties from UpToDate and Xlibris. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

No funding has been received.