The Use of Apremilast to Treat Psoriasis During Deployment

Abstract

Psoriasis is a chronic immune-mediated dermatologic disorder affecting approximately 2% of the general population. Under current U.S. Army regulation, the diagnosis of psoriasis is a bar to enlistment or appointment and, if poorly controlled, is grounds for referral to a Medical Evaluation Board and potential discharge from military service, according to Army Regulation 40-501. However, between 2008 and 2015, over 3,600 soldiers sought care for psoriasis while deployed to combat theaters, indicating that psoriasis remains a significant medical concern in the U.S. military. Although mild psoriasis is treatable with topical agents, moderate to severe psoriasis may require systemic treatment. Prior to Food and Drug Administration approval of apremilast (Otezla) in 2014, the standard systemic treatment options were methotrexate and biologic agents such as anti-Tumor Necrosis Factor-alpha medications. Active use of methotrexate or biologic immunomodulatory medications automatically disqualifies soldiers from deployment due to monitoring requirements, the need for refrigeration, and the risk for immune compromise. Apremilast offers treatment efficacy similar to that of methotrexate, and it may be taken while deployed because it does not require monitoring or refrigeration. However, efficacy must be evaluated in the context of its much higher unit cost. Nonetheless, we argue that apremilast may be a useful treatment option for psoriasis in a select group of soldiers who must deploy despite suffering from moderate to severe psoriasis.

Beyond-Mild Psoriasis: A Consensus Statement on Calcipotriol and Betamethasone Dipropionate Foam for the Topical Treatment of Adult Patients

“…Pregnancy or drug interactions may also limit treatment options [59]. Contraindications specific to biologics may include situations in which requirements for laboratory monitoring during treatment or refrigerated storage are not feasible [60], while cost may be an additional barrier [61].…”

Relevant Dermatoses Among U.S. Military Service Members: An Operational Review of Management Strategies and Telemedicine Utilization

“…Source: [93] Apremilast is a small-molecule biologic therapy approved by the US FDA for use in plaque psoriasis and PsA [93,144]. Additionally, it is approved by the military and does not disqualify soldiers from deployment.…”

“…Medications such as methotrexate and biologic immunomodulatory drugs should remain cold. Furthermore, medications, such as minocycline and isotretinoin, have a wide range of side effects, limiting safe use in a deployed setting [ 66 , 93 ].…”

Apremilast Uses and Relevance to the Military

“…33 Necessity dictates that treatment of this condition extend to theater operations; from 2008 to 2015, more than 3600 soldiers sought care for psoriasis while deployed to a combat theater. 34 In some cases, poorly controlled inflammatory skin conditions lead to medical separation. 33 Although there are limited data on the use of apremilast in the military, its use during deployment for the treatment of psoriasis and psoriatic arthritis has been reported, with the great majority of service members retaining their deployable status even 1 year after the study period.…”

“…The risk for immunosuppression with targeted immune therapy must be fully weighed, as certain duty stations and deployments might increase the risk for exposure to Mycobacterium tuberculosis, endemic mycopathogens, hepatitis C virus, HIV, Leishmania, and Strongyloides. 34 Furthermore, the tumor necrosis factor α inhibitors and IL-17 and IL-23 blockers used to treat psoriasis all require refrigeration; often, this requirement cannot be met in austere overseas settings. Additional requirements for laboratory monitoring, titration of medications, and frequent office visits might prohibit a service member from performing their duties, which, in turn, is detrimental to military readiness and the career of that service member.…”