Management of Common Side Effects of Apremilast

Abstract

Apremilast is a relatively new therapy for the treatment of moderate to severe plaque psoriasis in adults. While this medication is considered safe with a very low risk of serious side effects, a few common (≥5% of patients) mild to moderate side effects have been reported, including diarrhea, nausea, headache, and nasopharyngitis. Not addressing these symptoms may lead to medication nonadherence and unnecessary discontinuation of therapy. These side effects are often easily managed with interventions available to the practicing dermatologist, and in only rare instances will these side effects require dose adjustment or discontinuation of therapy. The purpose of this article is to review common side effects of apremilast at its approved dose of 30 mg orally twice daily (BID) and to provide clear, simple recommendations for their management in dermatological practice.

Apremilast induced chronic diarrhea and malnutrition

“…This oral medication is well tolerated with minimal risk of serious side effects. Commonly reported side effects are diarrhea, nausea, headache, nasopharyngitis, upper respiratory tract infection which are generally self resolving and do not require dose adjustment or discontinuation of therapy (3). Diarrhea due to apremilast is secretory in nature as it causes increases in intracellular cAMP levels within small intestinal crypt cells which activate chloride channels (5).…”

“…Diarrhea usually resolves within 4 weeks and it might be due to effect of compensatory up-regulation of other phosphodiesterases in the small intestinal crypt cells (6). Recommended management of apremilast induced diarrhea is to begin with non-pharmacologic interventions such as ensuring adequate hydration, having small frequent meals and limiting consumption of other potential triggers for diarrhea (3). Patients not responding to non-pharmacologic interventions can be treated with over the counter medications like fibre supplement, bismuth subsalicylate or loperamide (3).…”

“…Common side effects are diarrhea, nausea, headache, nasopharyngitis, upper respiratory tract infections and the reported incidence of diarrhea is close to 10 per 100 person-years (3). Diarrhea due to apremilast is secretory in nature which resolves spontaneously and do not require medical intervention, dose adjustment or discontinuation (3). We report a case of apremilast induced chronic diarrhea leading to malnutrition.…”

“…This drug is relatively safe at approved dose of 30 mg twice daily, causes a few self resolving mild to moderate side effects which generally do not require discontinuation of therapy (2). Common side effects are diarrhea, nausea, headache, nasopharyngitis, upper respiratory tract infections and the reported incidence of diarrhea is close to 10 per 100 person-years (3). Diarrhea due to apremilast is secretory in nature which resolves spontaneously and do not require medical intervention, dose adjustment or discontinuation (3).…”

Apremilast in psoriasis and beyond: Big hopes on a small molecule

“…Intractable diarrhea may necessitate pharmacological intervention with bulk-forming agents, bismuth subsalicylate, short-term loperamide, dose reduction, or even treatment discontinuation. [ 74 ]…”