'Is My Psoriasis Flare Due to Medications I’m Taking?' Transcript

Kaitlin: Hello, my name is Kaitlin Walden, and I'll be your moderator today on Psound Bytes™. I was initially diagnosed with plaque and scalp psoriasis at the age of 6 and experienced a guttate flare in my 20s. With me today to talk about the topic of potential medication interactions with psoriasis and psoriatic arthritis and tips for working with your pharmacist is Dr. Lacey Glover, who holds a doctorate in pharmacy.
Dr Glover is a Clinical Dermatology Pharmacist at the University of Alabama Medicine. She earned her Doctor of Pharmacy and Master of Public Health from Samford University. She is board-certified in ambulatory care and completed two years of postgraduate training with a focus on outpatient pharmacotherapy. In her current role, she assists with access to biologic medications as well as education and follow-up for skin diseases such as psoriasis, atopic dermatitis, hidradenitis suppurativa, and vitiligo. 

Welcome, Lacey, and thank you for taking time to join me today. Let's start our discussion by learning more about what you do in your role as a Clinical Dermatology Pharmacist. Can you please tell us how you help patients access biologic medications and what's involved in that process?

Dr. Glover: Yeah, of course. So I have a very unique role within our dermatology department. The focus of my role is mainly on safe medication usage and access. So within this role I see patients alongside providers in our clinic just in order to facilitate education and patient access. Not only do I submit prior authorizations for biologic medications, I also submit appeals, and assist with patient assistance programs grant enrollment essentially because what we want to make sure that not only can a patient be approved for medication, but that they can actually afford it, and access that medication. In addition to those duties, I also extensively counsel patients on administration and usage of biologic medications before they're dispensed. We have our own dispensing pharmacy, specialty pharmacy here, but of course there are also many other specialty pharmacies that patients may have to use based on their insurance. So my job is to also figure out where the medication needs to go. But once it's filled, I do counsel the patients and then I will actually follow up with the patient by phone or in clinic after about three or four months to assess if they've had a good start to the medication - if it started working, assessing side effects, and actually speaking with the patients about a lot of the medications that we're gonna go over today like any potential interactions and things like that. So it's been a very rewarding role and I really enjoy getting to see the whole process though from essentially diagnosis to treatment.

Kaitlin: That's great! Thank you so much for what you do to help those like myself who have psoriasis. So as I mentioned earlier, I've had plaque, scalp, and guttate psoriasis. Knowing what to avoid in medications and over-the-counter products is super important. What chemicals should I look for in over-the-counter products that could make my psoriasis worse?

Dr. Glover: That's a very important point that we often have to relay to patients when we start a medication for psoriasis or you know at first diagnosis. A big culprit chemical to watch out for is fragrances that I find that a lot of patients don't necessarily realize that's something that they need to look out for. So when our patients come into clinic, they like I said, don't realize how it can affect their psoriasis and make it worse. So we always tell our patients to look at the products they're using in their everyday life to make sure they're free of fragrances, dyes, alcohol, and essential oils. It can really dry out your skin. So another thing that I found too is that just because something says that it's like no scent, doesn’t mean that it doesn't have fragrance in it. So it's always just important to look and see that fragrance is not included in whatever substance that you're using, whether that be your dish detergent, laundry detergent, soap, shampoo. There's so many things that people don't realize have fragrance in them, so we always just want to make sure that they check those out before they use those products.

Kaitlin: That is such great advice. So could drinking alcoholic beverages impact the effectiveness of medications for psoriasis or psoriatic arthritis? And if so, what medications is this more likely to occur with?

Dr. Glover: Great question. So not only can alcohol actually worsen your psoriasis due to just increasing inflammation within your body, can also affect the medications we use to treat psoriasis. So one medication that we think about in particular is methotrexate, even though that's a little bit older school of a medication, a lot of our patients are still on it and it's appropriate to be on it. The combination of alcohol methotrexate can actually cause pretty significant liver damage. So one of the first questions we ask all of our patients here is if they are drinking before they start methotrexate or if they have begun drinking once they've started the medication. So methotrexate of course is important, but like I just mentioned other medications such as the systemic treatments and biologics, alcohol can actually increase the amount of inflammation in your body and cause a flare of psoriasis. So even if you're on a biologic or another systemic medication, alcohol in general can just really put your body in a very inflamed state, which can of course cause a flare of your psoriasis.

Kaitlin: That makes so much sense. Thank you for sharing that. Many in the psoriasis community have other related diseases which includes high blood pressure, heart disease. Some people could be taking medications that may place them at risk of flaring or make their psoriasis worse. What high blood pressure medication and heart medications could place someone at risk for a flare, and what should someone do if they notice flares of their disease while on these types of medications?

Dr. Glover: Yeah. So the first thing I want to emphasize is that not everyone who starts one of these medications that I'm gonna mention will have a flare in their psoriasis. Again, this is just something to be aware of because there is a risk of inducing a flare.  But it's actually not a given that it will happen to you. We just really want patients to be aware of these things if they do happen because it may be one of those times that your biologic medication or other medication is working for your psoriasis and we don't necessarily need to switch the medication or anything. We just need to know that it's not working for you because of a flare when using a different medication. So some of the most common blood pressure medications are beta-blockers such as atenolol, metoprolol and propranolol. Other blood pressure medications include ACE inhibitors, such as lisinopril or other medications that end in PRIL, as well as other heart medications like digoxin, quinidine, amiodarone, and gemfibrozil. Again, I just want to stress that you may not have a flare if you've started on one of these medications or are already on them, but it's important to let your dermatologist know if you're starting one of these medications, or if you think you're having a flare after being started on one. 

Kaitlin: Now talking about flares, how soon could a flare of psoriasis occur, if it's due to a potential use of another medication and when should someone be concerned and reach out to their healthcare provider to discuss?

Dr. Glover: So it can be very different for each medication. But in general, if a reaction is going to occur, it will usually happen within 1 to 12 months after starting the new medication. So if you think you're experiencing a flare because of an offending medication, it's important to reach out to the prescribing doctor so that may not be your dermatologist. That could obviously be your primary care provider, your cardiologist, but also let your dermatologist know before you stop any medication. So what they can essentially do is work together to find a better medication or treatment plan to ensure both your psoriasis and your other chronic conditions are effectively managed.

Kaitlin: Now something like non-steroidal anti-inflammatory drugs or NSAIDs are used to help reduce pain and swelling associated with PsA. In some people, naproxen and indomethacin have been linked to triggering psoriasis. If this occurs are there any NSAID choices that could be discussed with the healthcare provider?

Dr. Glover: Yes, great question. So many patients are on NSAIDS for their psoriatic arthritis and actually many NSAIDS have been triggered with psoriasis flares. So it can be hard when you have to treat both the arthritis along with the psoriasis. So some medication choices that are similar to NSAIDs are called meloxicam and celecoxib. These are technically Cox 2 inhibitors, but they've not had the same link in causing psoriasis flares as NSAIDS. I do want to just preface that both of those are prescription drugs. So again, that's something to talk about with your dermatologist, rheumatologist, or whoever is helping you with your psoriatic arthritis just to ask them if that's another option for you if you feel like one of the NSAIDS is causing your flare of psoriasis.

Kaitlin: That makes sense. I've also heard that there are some medications used to treat infections that could potentially make a flare of psoriasis worse. Could you please identify what those medications are and what options are available as an alternative?

Dr. Glover: So one of the first medications that comes to mind is an antibiotic called tetracycline, which can actually be used to treat infections such as pneumonia. But there are many alternatives to this antibiotic, like azithromycin. If that's something that your doctor is thinking about putting you on, again, it's a great time to make sure that your doctor is fully aware of your medical history, that you do have psoriasis. So that way, if that's one of the medications that they are thinking about starting you on, you can let them know that and maybe they can try a different antibiotic. Another medication is interferon. So that medication was used to treat hepatitis C. Interferon has actually fallen out of favor for the treatment of hepatitis C, so there are literally almost a dozen other medications that can be used that wouldn't affect your psoriasis, which I would also recommend. So again, working with your physician or your provider from wherever you're getting the hepatitis C medication, just letting them know upfront your medical history is really important so that way they know that you don't need to be on interferon because it can hurt your psoriasis. And lastly, terbinafine for fungal infections can also cause flares, but again, there are many antifungals out there such as fluconazole that can be used in the place of terbinafine. 

Kaitlin: This is such great information. Thank you so much. Another thing in the psoriasis community that is very prevalent is depression and anxiety. What medications used to treat mental health issues could potentially cause flares for psoriasis?

Dr. Glover: Yes, depression and anxiety is very, very common here in the psoriasis community. So some of the medications that are known to flare psoriasis that also treat anxiety and depression are fluoxetine, lithium, bupropion, alprazolam, clonazepam, and diazepam. So I just said a lot of medications, but what I do again want to really stress with this is that there are so many alternatives to these medications. So again, don't hesitate to reach out to a provider if you think one of these medications may be causing a psoriasis flare. 

Kaitlin: Now when thinking about biologics, we know that TNF-alpha inhibitors are effective biologics used by many people. However, for some people, use of TNF inhibitors can make their psoriasis worse. Do you mind explaining what this reaction is and why this occurs?

Dr. Glover: Yes. So this is something that I actually had never heard about until I started practicing in dermatology. And it's something that I have definitely seen a few times. So in the dermatology community, we call this paradoxical psoriasis, or TNF-alpha induced psoriasis. We call it this because it's a little counterintuitive, right? We use this medication to treat psoriasis, but it can actually cause psoriasis. Well it’s true. This can happen, and we're not entirely sure why it happens, but the thought is because TNF works so broadly in our immune system, some of the proteins can actually make the inflammation worse.

So I do just wanna clarify that only about 2 to 5% of patients on a TNF- alpha inhibitor will experience paradoxical psoriasis. But again, if you feel like you're on a TNF-alpha inhibitor and your psoriasis started to get worse or there's different characteristics of your psoriasis that you think hmmm that doesn't look like when I first got diagnosed with psoriasis, please reach out to your dermatologist because it may just be a simple switch to a different medication to help with your psoriasis flare. 

Kaitlin: I know from experience that corticosteroids can also cause a flare even erythrodermic psoriasis. Can you please explain when and why this occurs?

Dr. Glover: So I do wanna preface that steroids, especially topical steroids, when used appropriately can treat psoriasis and not cause flares. And what typically cause flares is when using strong steroids or very potent steroids such as clobetasol and triamcinolone, that abruptly stopping to use those. So this is actually called steroid withdrawal and this can make flares much worse. What we typically recommend is tapering off the steroid, which is essentially slowly working down the dose until you can stop it completely. So if you're on a higher dose or it's a very potent steroid and you're using it multiple times a day, we will slowly work you down on that so that way your body is used to it and it doesn't cause a flare. So that is why it's really important to follow directions from your physician and your pharmacist on how to use and taper off your steroids before you attempt to stop them yourself. 

Kaitlin: So Lacey, while we know not everyone will experience flares of their psoriasis while taking the medications we've discussed, why do you think some people who take such medications experience flares of psoriasis?

Dr.  Glover: In my pharmacy career, I've really noticed that every patient is very different.  Some patients will react a certain way to a medication or treatment regimen very differently from another patient. We all have slight differences in our metabolism and our immune systems, and it can really manifest differently for each patient. I've known patients who have had no issues when it comes to introducing some of the medications that we've discussed earlier and some who flare immediately when starting an offending medication. So it's really hard to predict who will react, but that's why it's important to be aware of the interactions and to reach out to your dermatologist if you think any medication is causing a flare.

Kaitlin: You emphasize the importance of discussing potential medication interactions with a pharmacist such as yourself or health care provider. What types of questions should someone ask when being prescribed new medications?

Dr. Glover: Definitely, I cannot recommend enough that patients feel comfortable discussing medication interactions with their pharmacists or provider. A few questions that patients can ask when being prescribed a new medication include “if I experience a flare when should I reach out to my provider” or “how can I communicate with you that I'm having a problem” because a lot of my patients can sometimes feel frustrated because they don't know how to reach us. So it's really important for us to just to go ahead if you ask that question, I'll clarify with you. You can send me a message in our patient portal. Here's my phone number. Please call me if you're having an issue just so that way I can know about it. And another great question is “can you explain what symptoms to look out for specifically for a psoriasis flare?” Again, there are many other questions that you can ask, but it's important to know how and when to reach your provider if you think you're having a flare and how to actually triage that.

Kaitlin: Thank you. That is some great information. Do you have any other tips to help the psoriasis community work effectively with their pharmacists?  

Dr. Glover: So something I've learned and appreciated since becoming a part of the dermatology team is when patients become an advocate for themselves. You know, it's impossible for me to know if a patient is having an issue with their medication. If they're not responding well to the medication. If they think they're having a side effect. If they think one of these offending medications has caused a flare of their psoriasis, or if they're not even able to fill their medication at a specialty pharmacy. I have no way of knowing that if you don't tell that to me. So I always encourage patients to be their biggest advocate and to advocate for their health. I wanna make sure all patients have the best chance for success. So again, please advocate for yourself if you're ever having any issues. That's what we're here for. We're here to help patients.               Kaitlin: What about some tips to help with insurance approvals for medications, especially things like biologics? 

Dr. Glover: It can really depend on the insurance plan, what they're going to require in order to get a medication approved. I'm sure that many people have talked about step therapy requirements and things like that, but what it really comes down to is clear documentation of the disease because most insurance companies will be fairly reasonable - if you meet their requirements. But if you know what their requirements are, you can a lot of times bypass some of those step therapies. So for example, if a patient has special site involvement, which is generally an area that's harder to treat, such as your hands, feet, scalp or genitals. Those actually usually requires an automatic approval if the documentation is there within the chart notes and the prior authorization. So again, just make sure if you're a patient that you tell your provider exactly where your psoriasis is affecting you, and if you're provider, make sure that you're clear in your documentation in how severe and where exactly the psoriasis is affecting your patient.

Kaitlin: Lacey, thank you for those tips which are so important to remember. This has been such an enlightening discussion about medication interactions. Do you have any final comments you would like to share with our listeners today? 

Dr. Glover:  Thank you all so much for having me, I hope that your listeners can just take away that myself and other pharmacists who work within the realm of dermatology hope to help all patients effectively manage their psoriasis, especially when it comes to medications that can actually worsen their psoriasis. Kaitlin: Thank you again Lacy for being here today. I've enjoyed our discussions about the various medications that could potentially place someone at risk for psoriasis flare. By sharing this information, our hope is that we've increased your knowledge about potential risks for psoriasis flares. Such risks occur for some, but not everyone will have the same experience. As Lacey mentioned, it's important for you to follow up with your health care provider if you experience any related side effects to medications you take. And for our listeners, if you know someone who can benefit from listening to this episode with Dr. Glover, please share the link to this episode with them. If you would like more tips on working with your pharmacist more effectively, contact our Patient Navigation Center at education@psoriasis.org.  And finally, thank you to our sponsor, Bristol Myers Squibb for their support of this Psound Bytes™ episode.