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Successful Treatment of Plaque Psoriasis With Self-administered Subcutaneous Alefacept

Successful Treatment of Plaque Psoriasis With Self-administered Subcutaneous Alefacept Alefacept is indicated for the treatment of moderate to severe plaque psoriasis and is administered as a course of 12 weekly intramuscular injections. The requirement for in-office administration of alefacept prevents the use of the drug for some patients who do not wish to visit the dermatologist weekly. For this reason, a patient of mine agreed to self-administer the intramuscular preparation of alefacept as a once-weekly subcutaneous injection. Report of a Case A 34-year-old woman presented with a 20-year history of chronic unremitting plaque psoriasis. The patient also had a history of multiple sclerosis, for which she had received intramuscular interferon beta-1a. She had discontinued the interferon beta-1a therapy 10 weeks previously. She denied any other medical problems and took no other medications. Her treatment history included UV phototherapy, topical corticosteroids, and topical calcipotriene. At presentation, her Psoriasis Area Severity Index was 9.0, with plaque psoriasis involving 10% of her body surface area, including her scalp, trunk, and extremities. Her baseline CD4 count was 689 cells/μL. A 12-week course of 15-mg alefacept therapy was initiated. During this treatment course, the patient chose to withhold all other forms of psoriasis therapy, including topical medications. With each dose, the patient resuspended the intramuscular preparation of alefacept as per the manufacturer’s instructions but used insulin needles and 1-mL syringes to self-inject the drug subcutaneously into her anterior thigh. Twenty-four hours after the initial injection, the patient experienced fever, chills, and myalgia. These symptoms dissipated soon thereafter and never reappeared after subsequent doses. By the sixth injection the patient noted significant improvement of her psoriasis at all body sites. After 10 weeks of self-treatment, her Psoriasis Area Severity Index had been reduced to 2.1, and by 2 weeks after her 12th dose it was lower than 1.0, with small plaques present only on the scalp. The rest of her body was clear. Throughout the course of therapy, CD4 counts were measured every other week, with 1 value measured below normal (week 10, 363 cells/μL). Her final CD4 count at the 12th week was 529 cells/μL. The patient denied any other adverse events during treatment. Comment To my knowledge, no published studies describe the pharmacokinetics of subcutaneous alefacept compared with either the intramuscular or intravenous administration of the drug. But the experience with this patient suggests that subcutaneous dosing delivers drug adequately, as shown by the appearance of flulike symptoms after administration, the reduction in CD4 count, and the improvement in the patient’s psoriasis at a rate consistent with that of the other routes of alefacept administration. The effect of the previous treatment with interferon for multiple sclerosis is unclear, but the patient reported that her psoriasis, surprisingly, always was milder while she received interferon. While the administration of alefacept as a subcutaneous injection is not approved by the US Food and Drug Administration, this approach may be practical for some patients who are unwilling or unable to make weekly office visits. The ability to measure CD4 counts every other week at a satellite facility may further facilitate this approach. Correspondence: Dr Strober, Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 560 First Ave, TCH-158, New York, NY 10016. Finanical Disclosure: Dr Strober serves on the Speakers Bureau for Biogen Idec, Cambridge, Mass. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Successful Treatment of Plaque Psoriasis With Self-administered Subcutaneous Alefacept

Archives of Dermatology , Volume 141 (12) – Dec 1, 2005

Successful Treatment of Plaque Psoriasis With Self-administered Subcutaneous Alefacept

Abstract

Alefacept is indicated for the treatment of moderate to severe plaque psoriasis and is administered as a course of 12 weekly intramuscular injections. The requirement for in-office administration of alefacept prevents the use of the drug for some patients who do not wish to visit the dermatologist weekly. For this reason, a patient of mine agreed to self-administer the intramuscular preparation of alefacept as a once-weekly subcutaneous injection. Report of a Case A 34-year-old woman...
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Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.141.12.1602-a
Publisher site
See Article on Publisher Site

Abstract

Alefacept is indicated for the treatment of moderate to severe plaque psoriasis and is administered as a course of 12 weekly intramuscular injections. The requirement for in-office administration of alefacept prevents the use of the drug for some patients who do not wish to visit the dermatologist weekly. For this reason, a patient of mine agreed to self-administer the intramuscular preparation of alefacept as a once-weekly subcutaneous injection. Report of a Case A 34-year-old woman presented with a 20-year history of chronic unremitting plaque psoriasis. The patient also had a history of multiple sclerosis, for which she had received intramuscular interferon beta-1a. She had discontinued the interferon beta-1a therapy 10 weeks previously. She denied any other medical problems and took no other medications. Her treatment history included UV phototherapy, topical corticosteroids, and topical calcipotriene. At presentation, her Psoriasis Area Severity Index was 9.0, with plaque psoriasis involving 10% of her body surface area, including her scalp, trunk, and extremities. Her baseline CD4 count was 689 cells/μL. A 12-week course of 15-mg alefacept therapy was initiated. During this treatment course, the patient chose to withhold all other forms of psoriasis therapy, including topical medications. With each dose, the patient resuspended the intramuscular preparation of alefacept as per the manufacturer’s instructions but used insulin needles and 1-mL syringes to self-inject the drug subcutaneously into her anterior thigh. Twenty-four hours after the initial injection, the patient experienced fever, chills, and myalgia. These symptoms dissipated soon thereafter and never reappeared after subsequent doses. By the sixth injection the patient noted significant improvement of her psoriasis at all body sites. After 10 weeks of self-treatment, her Psoriasis Area Severity Index had been reduced to 2.1, and by 2 weeks after her 12th dose it was lower than 1.0, with small plaques present only on the scalp. The rest of her body was clear. Throughout the course of therapy, CD4 counts were measured every other week, with 1 value measured below normal (week 10, 363 cells/μL). Her final CD4 count at the 12th week was 529 cells/μL. The patient denied any other adverse events during treatment. Comment To my knowledge, no published studies describe the pharmacokinetics of subcutaneous alefacept compared with either the intramuscular or intravenous administration of the drug. But the experience with this patient suggests that subcutaneous dosing delivers drug adequately, as shown by the appearance of flulike symptoms after administration, the reduction in CD4 count, and the improvement in the patient’s psoriasis at a rate consistent with that of the other routes of alefacept administration. The effect of the previous treatment with interferon for multiple sclerosis is unclear, but the patient reported that her psoriasis, surprisingly, always was milder while she received interferon. While the administration of alefacept as a subcutaneous injection is not approved by the US Food and Drug Administration, this approach may be practical for some patients who are unwilling or unable to make weekly office visits. The ability to measure CD4 counts every other week at a satellite facility may further facilitate this approach. Correspondence: Dr Strober, Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 560 First Ave, TCH-158, New York, NY 10016. Finanical Disclosure: Dr Strober serves on the Speakers Bureau for Biogen Idec, Cambridge, Mass.

Journal

Archives of DermatologyAmerican Medical Association

Published: Dec 1, 2005

Keywords: self administration,plaque psoriasis,alefacept

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