Considering that the patient had a high level of disease activity and comorbidities, we need to systemically treat to target with the goal of remission. She failed two DMARDs (MTX alone and acitretin) and phototherapy. 2015 GRAPPA treatment guideline suggest the use of biologics in this scenario.
Additionally, we would not continue MTX due to the increased risk for liver disease given her baseline fatty liver and diabetes; We would avoid prednisone given her diabetes, and we would avoid Cyclosporine due to hypertension.
According to 2016 GRAPPA recommendations, after a failure of a anti-TNFα, it’s recommended to switch to another biologic treatment (anti-TNFα, anti-IL12/23, anti-IL17) or a phosphodiesterase 4 inhibitor if the domain involved is dactylitis.
The corticosteroid injection could be a option for dactylitis but not for the skin manifestation; phototherapy and cyclosporine don’t have sufficient evidence to be indicated for dactylitis.
According to the 2015 guideline of the American Gastroenterology Association (AGA)*, patients using methotrexate are at low risk of reactivation of hepatitis B (<1%) but all biologics currently used for psoriasis treatment are considered of moderate risk (1 – 10% of reactivation) if both HBsAg and anti-HBc are positive. If HBsAg is negative and anti-HBc positive, the risk is lower but there is less evidence to support a recommendation for no prophylaxis, so the AGA suggest to propose the prophylaxis for all patients who will use biologic agent and are anti-HBc positive.
Thus, screening for active hepatitis B and C and subclinical or previous hepatitis B is recommended prior to starting biologics.
While there is not specific evidence guiding the decision in this case, the 2016 GRAPPA recommendations suggest to consider to switch for another biologic or PDE4i for the skin domain. Option D was incorrect as there is not data to suggest improved cardiovascular safety for any one of these options.
According to the 2015 guideline of the American Association of Gastroenterology*, patients with prior HBV (core Ab +) using biologics should use antiviral prophylaxis during therapy and for 6 months after the discontinuation of the biologic besides the monitoring with liver enzymes and PCR for DNA HBV.
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