Apremilast

Apremilast (trade name Otezla) is used to treat psoriasis (saw-rye-a-sis) and psoriatic arthritis (saw-ree-at-ik arth-ri-tis).

It's a type of disease-modifying anti-rheumatic drug (DMARD). It targets an enzyme called PDE4, which is involved in the inflammatory processes that cause the symptoms of these conditions.

Apremilast has been shown to reduce symptoms such as swollen and tender joints and to improve skin symptoms, including scalp and nail psoriasis. If apremilast works for you, you should start to notice the benefits within four months of starting the treatment.

Apremilast can be prescribed by a rheumatology consultant or other clinical specialist in rheumatology.

Apremilast is taken as tablets. They can be taken with or without food.

When you first start taking apremilast, you’ll be given a special starter pack which contains all the doses for the first six days. The pack is clearly labelled to make sure you take the right dose at the right time, starting with a low dose and working up to the maximum.

Once you’ve finished the starter pack, you’ll remain on the higher dose. Most people will take one tablet in the morning and one in the evening. However, if you have kidney problems, your specialist may suggest just taking one tablet a day.

If you miss a dose, contact your specialist team immediately for advice on when to take the next one.

Because apremilast is a long-term treatment, it’s important to keep taking it, unless you have severe side effects:

• even if it doesn’t seem to be working at first
• even when your symptoms improve, to help keep your condition under control.

Your doctor may decide to stop the treatment after four months if there hasn’t been enough improvement in your symptoms.

Your doctor may decide not to prescribe this treatment if:

• you haven't tried other treatments first
• you have symptoms of depression
• you're pregnant or planning to try for a baby
• you have a lactose intolerance
• you're underweight.

Your doctor will assess your condition and may decide to do some tests, for example kidney function tests, before starting this treatment.

Like any medicine, apremilast can cause side effects but many people won’t have any problems. You should speak to your rheumatology team if you’re worried about side effects.

Common side effects can include:

• diarrhoea
• feeling sick
• coughs and colds
• headaches.

These mostly occur within a few weeks of starting apremilast treatment and are usually mild enough to clear up without any special treatment.

Other more serious side effects you should be aware of include:

• feelings of depression or suicidal thoughts: These are very rare side effects but can be very serious, so contact your doctor straight away if you start to feel like this at all.
• loss of weight: Tell your doctor if you have unexplained or significant weight loss after starting apremilast. It may be best for you not to continue the treatment.

If you pick up an infection while you're on apremilast, speak to your rheumatology team. If the infection is serious, you may need to stop taking apremilast until you’re better.

Reducing the risk of infection

• Try to avoid close contact with people you know have an infection.
• Wash your hands regularly and carry around a small bottle of antibacterial hand gel.
• Keep your mouth clean by brushing your teeth regularly.
• Stop smoking if you're a smoker.
• Make sure your food is stored and prepared properly.
• Try to keep your house clean and hygienic, especially the kitchen, bathrooms and toilets.

You may be taking other disease-modifying drugs as well as apremilast. However, apremilast can interact with some medicines, so check with your doctor or a pharmacist before starting any new medicines. Remember to mention you're on apremilast if you’re treated by anyone other than your usual rheumatology team.

You can carry on taking non-steroidal anti-inflammatory drugs (NSAIDs) or painkillers, if needed, unless your doctor tells you otherwise.

Don't take over-the-counter or herbal medicines without discussing it first with your doctor. Some of these, including St John’s Wort, can interfere with the treatment.

Vaccinations

Live vaccines aren't usually recommended for people who are already on apremilast. These include yellow fever, rubella and oral polio vaccines.

A new non-live shingles vaccine is now available to those who are immunocompromised, making this a safe vaccine to have if you are taking apremilast.

It is recommended that you have the vaccination against COVID-19 as well as the pneumonia vaccine and yearly flu vaccine while you are taking apremilast. These vaccines are not live, so it's safe for you to have them.

Having an operation

If you're thinking about having surgery, check with your rheumatology team and surgeon about whether you should stop taking apremilast for a time before and after surgery.

There’s no known interaction between apremilast and alcohol. However, alcohol can make psoriasis worse, so it’s best to keep well within the recommended limits of no more than 14 units of alcohol per week for adults.

There's limited information available about the possible effects of apremilast in pregnancy. People who could become pregnant should use effective contraception while being treated with apremilast.

If you’re planning to try for a baby or if you’re already pregnant, your doctor won't prescribe apremilast.

Similarly, because we don't yet know if the drug can pass into human breast milk, you shouldn’t take apremilast if you’re breastfeeding.

There’s currently no information on whether apremilast might affect male or female fertility.