Apremilast Treatment Guidelines

Introduction

Apremilast is indicated for moderate-to-severe psoriasis, and documentation of disease severity, previous treatments tried, reasons for discontinuation, and impact of psoriasis on quality of life are essential for coverage approval, as recommended by the American Academy of Dermatology 1, 2

The American Academy of Dermatology recommends initiating apremilast at a lower dose of 10 mg on day 1 and titrating up over 5 days to the maintenance dose of 30 mg twice daily to reduce the risk of gastrointestinal adverse effects, following the FDA-approved titration schedule:
Day Morning Dose Evening Dose
1
10 mg
2 10 mg 10 mg
3 10 mg 20 mg
4 20 mg 20 mg
5 20 mg 30 mg
6+ 30 mg 30 mg
1
For patients with severe renal impairment (creatinine clearance <30 mL/min), the dose should be reduced to 30 mg once daily 1

The most common adverse effects associated with apremilast include diarrhea, nausea, upper respiratory tract infections, and headache, with most gastrointestinal adverse effects occurring within the first 2 weeks of treatment and resolving within the first month of treatment 1
Patients should be monitored for weight loss >5% from baseline, which may require discontinuation of therapy, and signs of depression or suicidal ideation, which have been reported in approximately 1% of patients 1
Elderly patients (≥65 years) are at higher risk for dehydration complications from gastrointestinal side effects and should be monitored more closely 1

No routine laboratory monitoring is required for patients on apremilast, which is an advantage over many other systemic psoriasis treatments, as specified by the American Academy of Dermatology guidelines 1
Apremilast is appropriate for moderate-to-severe plaque psoriasis (BSA >3% or PASI score indicating moderate-to-severe disease) and patients with psoriatic arthritis with skin involvement, with documentation of disease severity metrics, such as BSA affected and PASI score, necessary for optimal coverage approval 1, 2, 3
Primary code from L40.50-L40.59 series should be used for the arthritis component, and secondary code L40.0 for the skin manifestation when prescribing apremilast for patients with both skin and joint involvement, with coding updated when disease pattern changes 1, 2

Apremilast is metabolized by cytochrome P450, and use with strong CYP450 inducers (e.g., rifampin, phenobarbital, carbamazepine, phenytoin) is not recommended as it may decrease apremilast efficacy 1