Drugs affecting the immune response

13.5.3 Drugs affecting the immune response

Drugs affecting the immune response are used for ecz- ema or psoriasis. Systemic drugs acting on the immune system are used under specialist supervision.

Pimecrolimus by topical application is licensed for mild to moderate atopic eczema . Tacrolimus is licensed for topical use in moderate to severe atopic eczema. Both are drugs whose long-term safety and place in therapy is still being evaluated and they should not usually be considered first-line treatments unless there is a specific reason to avoid or reduce the use of topical corticoster- oids. Short-term treatment with topical pimecrolimus or topical tacrolimus should be initiated only by prescri- bers experienced in treating atopic eczema; continuous long-term treatment should be avoided.

NICE guidance Tacrolimus and pimecrolimus for atopic eczema (August 2004) Topical pimecrolimus and tacrolimus are options for atopic eczema not controlled by maximal topical corticosteroid treatment or if there is a risk of important corticosteroid side-effects (particularly skin atrophy). Topical pimecrolimus is recommended for moderate atopic eczema on the face and neck of children aged 2–16 years and topical tacrolimus is recommended for moderate to severe atopic eczema in adults and children over 2 years. Pimecrolimus and tacrolimus should be used within their licensed indications.

For the role of topical corticosteroids in eczema, see section 13.5.1, and for comment on their limited role in psoriasis, see section 13.4. A short course of a systemic corticosteroid (section 6.3.2) can be given for eczema flares that have not improved despite appropriate topi- cal treatment.

Ciclosporin (cyclosporin) by mouth can be used for severe psoriasis and for severe eczema. Azathioprine (section 8.2.1) or mycophenolate mofetil (section

8.2.1) are used for severe refractory eczema [unlicensed indication]. Hydroxycarbamide (hydroxyurea) (section

8.1.5) is used by mouth for severe psoriasis [unlicensed indication].

Methotrexate can be used for severe psoriasis, the dose being adjusted according to severity of the condition and haematological and biochemical measurements; the usual dose is methotrexate 10 to 25 mg once weekly, by mouth. Folic acid 5 mg (section 9.1.2) can be given once weekly to reduce the possibility of side-effects asso- ciated with methotrexate; alternative regimens of folic acid may be used in some settings.

Etanercept, a cytokine modulator, is used for severe plaque psoriasis either refractory to at least 2 systemic treatments and photochemotherapy, or in patients intol- erant of these treatments. Efalizumab (which inhibits T- cell activation) or another cytokine modulator, adali- mumab or infliximab, are alternatives. Adalimumab, etanercept, and infliximab are also licensed for psoriatic arthritis (section 10.1.3).

NICE guidance 1 Adalimumab for plaque psoriasis in adults (June 2008) Adalimumab is recommended for the treatment of severe plaque psoriasis which has failed to respond to standard systemic treatments (including ciclos- porin and methotrexate) and photochemotherapy, or when standard treatments cannot be used because of intolerance or contra-indications. Adalimumab should be withdrawn if the response is not adequate after 16 weeks.

NICE guidance Etanercept and efalizumab for plaque psoriasis in adults (July 2006) Etanercept is recommended for severe plaque psor- iasis which has failed to respond to standard sys- temic treatments (including ciclosporin and metho- trexate) and to photochemotherapy, or when standard treatments cannot be used because of intolerance or contra-indications. Etanercept should

be withdrawn if the response is not adequate after 12 weeks. Efalizumab is recommended for severe plaque psor- iasis which has failed to respond to etanercept or when etanercept cannot be used because of intoler- ance or contra-indications. Efalizumab should be withdrawn if the response is not adequate after 12 weeks.

NICE guidance Infliximab for plaque psoriasis in adults (January 2008) Infliximab is recommended for the treatment of very severe plaque psoriasis which has failed to respond to standard systemic treatments (including ciclos- porin and methotrexate) or to photochemotherapy, or when standard treatments cannot be used because of intolerance or contra-indications. Inflix- imab should be withdrawn if the response is not adequate after 10 weeks.