Comparative study of oral Methotrexate vs oral Methotrexate along with Apremilast in patients with Moderate to Severe Chronic Plaque Psoriasis

Psoriasis is a chronic inflammatory cutaneous disorder, affecting up to 2%-5% of the world population. The major manifestation of psoriasis is erythematous, scaly patches or plaques on the skin that are occasionally pruritic but have a significant impact on patient’s Quality of Life due to chronicity of the disease and frequent remissions and relapses. Psoriasis is a predominantly a T-cell mediated disorder occurring in genetically susceptible individuals, influenced by environmental factors. Methotrexate is a standard, cheaper drug for psoriasis with excellent efficacy but limited safety profile while Apremilast is a newer molecule with excellent safety profile. Comparing the standard drug alone with addition of newer drug will help in identifying better treatment options for psoriasis in terms of efficacy and safety in a disease which requires long term treatment. Methotrexate acts on cell cycle so have higher side effects like Neutropenia, Bone marrow suppression, Liver fibrosis, etc. Apremilast is a biologic which acts via Cyclic AMP pathway. So it has lesser toxicity and side effects than methotrexate. Apremilast can cause increase URTI, Flu-like symptoms in few patients. Apremilast is out of reach for common people because of its prohibiting cost. But nowadays this drug is not that costly. So adding oral Apremilast in Patients with moderate to severe psoriasis, dose of the Methotrexate can be reduced and can be stopped early and low dose oral Apremilast will be continued for a longer time. Whenever disease exacerbates, we can either increase the dose of oral Apremilast or add oral Methotrexate to control the activity. So over long run cumulative dose of Methotrexate can be reduced and toxicity can be decreased.