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DOI: 10.1111/ddg.13516
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Guidelines S3 Psoriasis guideline
Summary
The German guideline for the treatment of psoriasis vulgaris was updated using
GRADE methodology. The guideline is based on a systematic literature review com-
pleted on December 1, 2016, and on a formal consensus and approval process. The
fi rst section of this short version of the guideline covers systemic treatment options
considered relevant by the expert panel and approved in Germany at the time of the
consensus conference (acitretin, adalimumab, apremilast, cyclosporine, etanercept,
fumaric acid esters, infl iximab, methotrexate, secukinumab and ustekinumab). De-
tailed information is provided on the management and monitoring of the included
treatment options.
This is a short version of the German evidence- and con- The literature search was performed on September 30, 2016,
sensus-based (S3) guideline for the treatment of psoriasis vul- using Embase Ovid (1980 to September 29, 2016), MED-
garis. The long version is available at www.awmf.org. Please LINE Ovid (1946 to the third week of September 2016),
refer to the long version for the following sections: introduc- MEDLINE(R) In-Process & Other Non-Indexed Citations
tion, aims of the guideline, indicators of quality of care, inst- Ovid (September 29, 2016) databases and the Cochrane Cen-
ructions on using the guideline, detailed description of metho- tral Register of Controlled Trials CENTRAL. Autoalerts
dology, defi nition of the severity of psoriasis vulgaris, quality were screened up to December 1, 2016. The evidence was as-
of life, treatment aims, treatment costs, benefit-risk assess- sessed according to the methods recommended by Cochrane,
ment and basic therapy. The sections on biosimilars, climate including GRADE methodology [1].
therapy, psychosocial therapy, topical therapy, phototherapy,
interfaces between different providers and sectors of care, and
references can also be found in the long version. The guideline Passages requiring consensus
is an update, and some sections of the text have been taken The authors of the guideline have defined certain parti-
from the previous version of the guideline from 2011. cularly relevant sections as requiring consensus. These
passages were agreed on in consensus conferences and are
highlighted using gray boxes.
Methods
At their initial meeting, the authors of the guideline agreed on
the main points that required updating. It was decided to in- Treatment recommendation
clude new sections on “Special patient populations” and “Spe-
cial treatment situations” and not to update the sections on to- At present, there is no distinct stepwise procedure or
pical therapy, phototherapy, climate therapy and psychosocial strict clinical algorithm for the treatment of psoriasis vul-
therapy as major changes were not anticipated in the content garis. The criteria for selecting appropriate therapies are
of the recommendations in these areas. However, the import- complex.
ance of these therapies continues unchanged, and the recom- Key recommendations formulated in the text are aug-
mendations are included in the appendix of the long version. mented by symbols representing the strength of the treatment
Phototherapy (PUVA, UV) should be regarded as a separate recommendation. The following symbols were used to stan-
treatment category and is not considered a “systemic therapy”. dardize the treatment recommendations:
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Figure 1 Overview of evaluated treatment options for chronic psoriasis vulgaris (the order is alphabetical and does not indicate
priority).
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Updates/validity Acitretin
This is an update of the S3 guideline for the treatment of pso-
Treatment Consensus Comment
riasis vulgaris published in 2011 [2]. Some text passages have
recommendations strength
been included without change. The current version is valid
until December 31, 2020. Acitretin may be con- ã Consensus Evidence- and
sidered for induction consensus-
therapy of moderate based
Therapeutic options and treatment to severe psoriasis
evaluation vulgaris.
Acitretin cannot be å Strong Clinical
Figure 1 provides an overview of evaluated treatment options recommended in consensus consensus point
for chronic psoriasis vulgaris. women of child-bea-
ring age with psoria-
Systemic therapies sis vulgaris.
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Recommended Individual dose depends on outco- Table 2 Important adverse reactions associated with acitretin.
maintenance dose me and tolerability. Maintenance
Very common Hypervitaminosis A (e.g., associated with
dose: 25–50 mg per day
xerosis of the skin and mucous membra-
Onset of clinical Insufficient data [3] nes), cheilitis, elevated transaminases and
effect AP, elevated serum levels of triglycerides
Selection of main – Renal and hepatic damage and cholesterol
contraindications – Severe hyperlipidemia Common Conjunctivitis (caution: contact lenses),
– Women of child-bearing age effluvium, photosensitivity
who plan to have children
Occasional Muscle, joint and bone pain
– Pregnancy
– Breast-feeding Rare Gastrointestinal symptoms, hepatitis,
– Use of contact lenses jaundice, bone changes with long-term
therapy
Selection of – Hypervitaminosis A such as chei-
important ADRs litis, xerosis, epistaxis, alopecia, Very rare Pseudotumor cerebri, night blindness
increased skin fragility, elevation
of triglyceride and cholesterol
levels A selection of important ADRs can be found in Table 2 .
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Table 3 Prevention of adverse reactions associated with Depending on the clinical situation, fewer or more mea-
acitretin. sures or laboratory tests may be required. They should
be selected for each patient on an individual
Adverse drug Management
basis.
reactions (ADRs)
Pretreatment measures
Dry skin and mu- Use of moisturizing agents (pos- – Rule out alcohol abuse
cous membranes sibly including the nasal mucosa), – Inform the patient about the teratogenic risk and need
artificial tears, avoid wearing cont- for prolonged contraception until three years after the
act lenses conclusion of treatment (verbal and written informed
Diffuse alopecia Inform the patient about the rever- consent with signature)
sible nature of this adverse drug – Inform the patient that blood must not be donated
reaction during treatment and up to three years thereafter.
– Ask about bone and joint pain
Photosensitivity Avoid exposure to sunlight, use
– For laboratory tests, see Table 4
sunscreen
Measures during treatment
Elevation of serum Alcohol abstinence, low-fat and – Long-term treatment (roughly one to two years): if
lipids and/or liver low-carbohydrate diet, lipid-lowe- there are any symptoms, radiographic imaging of the
function tests ring agents (gemfibrozil or atorva- spine and joints is recommended to rule out potential
statin) ossification.
If levels fluctuate: monitor fre- – For women of child-bearing age: effective contracep-
quency and discontinue treatment tion and avoidance of alcohol consumption during
if necessary treatment.
Muscle and bone If symptoms persist: X-ray imaging, – Reminder that blood must not be donated during and
pain NSAIDs, avoid excessive physical until three years after treatment.
activity – For laboratory tests, see Table 4
Generalized edema Discontinue treatment, schedule – Patients with risk factors for cardiovascular disease, e.g.,
(rare) renal function tests hypertension, should be monitored regularly.
Posttreatment measures
– Remind patients that they must not donate blood
until three years after discontinuation of
– Concomitant use of high doses of vitamin A and other sys- treatment.
temic retinoids is not advisable. – Effective contraception* in women of child– bearing
– When used concomitantly with methotrexate, there is an age until three years after treatment.
increased risk of toxic hepatitis. – For women of child-bearing age: avoid alcohol
– The contraceptive effect of the low-dose progesterone pill consumption until two months after discontinuation of
(minipill) may be reduced by concomitant use of acitretin. treatment.
*Double contraception is recommended, e.g., condom +
Notes on use pill; coil/Nuva ring + pill; Caution: avoid low-dose proges-
terone products (minipill), as their effectiveness is reduced
The capsules should preferably be taken during a fatty meal
by acitretin.
or with whole milk. To ensure that the patient is not preg-
nant, treatment should be started on the second or third day
of the menstrual cycle if this has been preceded by reliable
contraception for at least one month. In some patients, acitre-
tin is converted to etretinate, which is facilitated by alcohol Table 4 provides an overview of laboratory tests for acitre-
consumption. Alcohol is therefore prohibited in women of tin therapy recommended by the expert group.
child-bearing age while they are taking the drug and for two
months after discontinuation of treatment. Given that acitre- Overdose/management of overdose/feasibility/
tin may be converted to etretinate, women of child-bearing costs and special considerations
age must continue to use contraception until three years after
discontinuation of treatment. See long version.
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Point in time ã Diagnostic tests å Before After After After Then every
treatment 4 weeks 8 weeks 12 weeks 3 months
Complete blood count* X X X X X
Liver function tests** X X X X X
Renal function tests*** X X X X X
Triglycerides, cholesterol, HDL**** X X X X X
Pregnancy test (urine) (monthly for X X monthly
3 years after treatment)
Fasting blood glucose***** X X
Depending on the clinical situation, fewer or more measures or laboratory tests may be required. They should be selected
for each patient on an individual basis.
*Complete blood count (Hb, Hct, leukocytes, platelets).
**AST, ALT, AP, GGT.
***Creatinine, urea.
****Preferably measured twice with patient in fasting state (2 weeks before and on the day of treatment initiation).
*****Given that retinoids can affect glucose tolerance in diabetic patients, more frequent glucose measurements are recom-
mended during the initial phase of treatment.
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Point in time ã Diagnostic Before treatment After 4 weeks After 12 weeks Then every 3
tests å months
CBC with differential X X X X
AST, ALT, GGT X X X X
Hepatitis B serology X
HIV and hepatitis C serology* X
Pregnancy test (urine) X
If infection is suspected, see pretreatment measures
According to the Summary of Product Characteristics, no laboratory tests are currently suggested during treatment with
adalimumab. The guideline authors recommend the tests listed above. Depending on the clinical situation, fewer or more
measures or laboratory tests may be required. They should be selected for each patient on an individual basis.
*As indicated by patient history, clinical signs or other laboratory test results.
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Pretreatment measures
– For laboratory tests see Table 6 Cyclosporine
– Rule out pregnancy and initiate contraception in women
of child-bearing age. Treatment recommendations Consensus Comment
– For patients with a history of psychiatric symptoms or strength
patients taking medications likely to cause psychiatric
Cyclosporine may be ä Strong Evidence-
symptoms, the benefits of apremilast treatment should
recommended for consensus and con-
be carefully weighed against the risks.
induction therapy of mo- sensus-
– Measure body weight
derate to severe psoriasis based
Measures during treatment
vulgaris.
– Interruption of treatment if the patient becomes pregnant
A combination of ä Strong Evidence-
– Discontinuation of treatment if there are new-onset psy-
cyclosporine and topical consensus and con-
chiatric symptoms or exacerbation of existing symptoms
preparations to treat sensus-ba-
or suicidal ideation or attempted suicide
moderate to severe sed
– Contraception
psoriasis vulgaris may be
– Weight should be monitored in underweight patients
recommended.
(BMI < 18.5 kg/m2)
– For laboratory tests see Table 6
Posttreatment measures
Cyclosporine summary table
– None
Approval of cyclosporine 1983 (transplantation
Table 6 Laboratory tests in patients on apremilast. in Germany medicine)
1993 (psoriasis vulgaris)
Point in time ã Before Every 3 Recommended initial 2.5–3 (max. 5) mg/kg body
Diagnostic tests å treatment months dose weight
CBC with differential X X Recommended main- Intermittent therapy
ALT, AST, GGT * X X tenance dose (each cycle 8–16 weeks)
with a dose reduction at
Serum creatinine* X X
the end of induction
Pregnancy test (urine) X therapy (e.g., 0.5 mg/kg body
According to the Summary of Product Characteristics, no weight every 14 days) or
laboratory tests are currently suggested during treatment continuous long-term
with apremilast. The guideline authors recommend the therapy with dose reducti-
tests listed above. Depending on the clinical situation, on, e.g., by 50 mg every 4
fewer or more measures or laboratory tests may be re- weeks after week 12 and dose
quired. They should be selected for each patient on an increase by 50 mg in case of
individual basis. recurrence
*Tests recommended due to need for dose adjustment in Onset of clinical effect PASI 75 response in 25 %
the case of renal failure as well as lack of experience in pati- of patients after 6 weeks
ents with impaired hepatic function. (<5 mg/kg body weight) [ 3]
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Table 7 provides an overview of the laboratory tests for Recommended initial 25 mg twice, 50 mg once, or
cyclosporine therapy recommended by the expert group. dose 50 mg twice per week
Overdose/management of overdose Recommended main- 25 mg twice per week, 50 mg
See long version. tenance dose once per week
Onset of clinical effect PASI 75 response in 25 % of pa-
Feasibility and costs
tients after 6.6 weeks (50 mg
See long version.
twice) or 9.5 weeks (50 mg
once/25 mg twice) [3]
Etanercept
Selection of main con- NYHA class III–IV heart failure,
Treatment Consensus Comment traindications active tuberculosis or other seri-
recommendations strength ous infection
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Important relative contraindications Table 8 provides an overview of the laboratory tests for
etanercept therapy recommended by the expert group.
– Demyelinating diseases
– Malignancy (except for basal cell carcinoma) and lympho-
Overdose/management of overdose
proliferative disorders or a history thereof No dose-limiting toxicity was observed in clinical studies of
– Pregnancy and breast-feeding patients with rheumatoid arthritis [8]. There is no known
– Vaccination with live vaccines antidote to etanercept.
Point in time → Diagnostic tests ↓ Before treatment Week 4 Week 12 Every 3 months
CBC with differential X X X X
AST, ALT, GGT X X X X
Hepatitis B serology X
HIV and hepatitis C serology* X
Pregnancy test (urine) X
If infection is suspected, see pretreatment measures
According to the Summary of Product Characteristics, no laboratory tests are currently suggested during treatment with
etanercept. The guideline authors recommend the tests listed above. Depending on the clinical situation, fewer or more
measures or laboratory tests may be required. They should be selected for each patient on an individual basis.
*As indicated by patient history, clinical signs or other laboratory test results.
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Feasibility and costs ters need between two and four Fumaderm® tablets per day.
The dose is increased until an adequate clinical response is
See long version. obtained. The individual maintenance dose is subsequently
established by gradual dose reduction.
Fumaric acid esters Fumaric acid ester treatment may be discontinued ab-
ruptly without any rebound effects or pustular flare-ups.
Treatment recommendations Consensus Comment Fumaderm® contains a mixture of fumaric acid esters,
strength the main ingredient being dimethyl fumarate.
Treatment with fumaric ↑ Strong Evidence-
acid esters may be recom- consensus and con- Summary of the evidence
mended for induction the- sensus-
rapy of moderate to severe based See long version.
psoriasis vulgaris.
Adverse drug reactions/safety
Fumaric acid esters summary table See long version and Summary of Product Characteristics.
Approval of fumaric 1994 (psoriasis vulgaris, modera- Gastrointestinal complaints (in up to 60 % of patients,
acid esters in Germany te to severe) especially in the fi rst weeks of treatment) and flushing are the
Recommended initial According to recommended do-
most common adverse effects associated with fumaric acid
dose sing regimen
ester therapy. Gastrointestinal tolerability can be improved
by taking the tablets with milk. Acetylsalicylic acid at a dose
Recommended main- Individual dose adjustment
of 500 mg may help at the fi rst signs of flushing.
tenance dose
Leukopenia, lymphopenia and eosinophilia are fre-
Onset of clinical effect Insufficient data [3]
quently observed during treatment with fumaric acid esters.
Selection of main con- – Severe gastrointestinal disea- The dose must be halved if the lymphocyte count falls below
traindications ses such as gastric and duo- 700/μ L. If there is no rebound of the lymphocyte count af-
denal ulcers ter four weeks, fumaric acid ester therapy must be discon-
– Severe liver or kidney disease tinued. A drop in lymphocytes below 500/μ L requires im-
Selection of important – Gastrointestinal symptoms mediate discontinuation of treatment. Patients who develop
ADRs – Flushing lymphopenia should be monitored for signs and symptoms
– Lymphopenia of opportunistic infections, especially neurological deficits
– Eosinophilia and cognitive or psychiatric symptoms, which may indicate
Selection of important Methotrexate, retinoids, psoralens, progressive multifocal leukoencephalopathy (PML). The in-
drug interactions cyclosporine, immunosuppres- crease in eosinophils is always transient and usually occurs
sants, cytostatic agents and drugs between weeks four and ten.
with a known harmful effect on
the kidneys must not be used con- Table 9 Dosing regimen for treatment with fumaric acid
comitantly with fumaric acid esters esters.
Miscellaneous –
Fumaderm® initial Fumaderm®
Week 1 0-0-1
Dosage and dosing regimen
Week 2 1-0-1
The standard clinical procedure consists of slow dose escala- Week 3 1-1-1
tion according to an established dosing regimen (Table 9). Week 4 1-0-0
The gradual dose increase is intended to improve tolerability,
Week 5 1-0-1
especially with regard to gastrointestinal symptoms.
The dose must be adjusted individually depending on the Week 6 1-1-1
response to treatment and occurrence of adverse effects. The Week 7 2-1-1
recommended maximum dose is 1.2 g per day = six Fuma-
Week 8 2-1-2
derm® tablets; however, effective treatment does not always
require this dose. Most patients treated with fumaric acid es- Week 9 2-2-2
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Renal impairment (proteinuria) is occasionally observed Table 10 Laboratory tests in patients on fumaric acid esters.
and is generally thought to resolve following dose reducti-
on or discontinuation of the drug. Secondary osteomalacia Point in time → Before Every 4 Every 8
(Fanconi syndrome) is a very rare complication that requires Diagnostic tests ↓ treat- weeks weeks
cessation of fumaric acid ester therapy. ment from
Dose adjustment is not required in elderly patients or in- month 4
dividuals with impaired liver function as fumarates are not Complete blood count* X X X**
primarily metabolized through the liver.
Liver function tests*** X X X
Prevention/management of ADRs Serum creatinine X X X
If adverse drug reactions occur, the dose should initially be re- Urinalysis**** X X X
duced; persistent reactions require treatment discontinuation. Depending on the clinical situation, fewer or more mea-
sures or laboratory tests may be required. They should be
Main contraindications/limitations of use selected for each patient on an individual basis.
*Erythrocytes, leukocytes, platelets, CBC with differential
Absolute contraindications **The current Summary of Product Characteristics requi-
– Severe hepatic or renal impairment res a CBC with lymphocyte count on a monthly basis; the
– Severe gastrointestinal disease guideline authors consider 8-week intervals to be suffi-
cient and do not believe that patient safety is improved
Important relative contraindications with more frequent monitoring.
***Transaminase, GGT.
– Pregnancy and breast-feeding
****If repeatedly positive for protein or glucose, Fanconi
– Comedication with MTX, retinoids, psoralens, cyclospori-
syndrome should be ruled out.
ne, immunosuppressants, cytostatic agents and drugs with
a known deleterious effect on the kidneys
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Selection of main cont- NYHA class III–IV heart ring with emergency equipment readily available is required
raindications failure, active tuberculosis during and for an hour after the infusion. Serum sickness can
or other serious infection, develop three to twelve days thereafter.
known hypersensitivity to Re-initiation of the drug after a prolonged treatment-free
mouse proteins interval may cause arthralgia, myalgia, angioedema and
Selection of important Infusion reactions, severe other acute reactions.
ADRs infections, autoimmune phe- Moderate infusion reactions can be mitigated or even
nomena prevented by prior administration of an antihistamine [9].
Production of infl iximab antibodies can be reduced by use of
Selection of important Anakinra (IL1-R antagonist) or
low-dose MTX (5–10 mg/week) [10, 11].
drug interactions abatacept
Miscellaneous – TNF-alpha antagonist Infections
– Not approved for use in
Infl iximab therapy has been associated with severe infec-
children with psoriasis
tions including sepsis, sometimes even fatal. Patients with
obvious, clinically relevant infections should therefore not
Dosage and dosing regimen be treated with infl iximab. There have also been rare cases
of opportunistic infections, including listeriosis, histoplas-
The dose required for treatment of psoriasis vulgaris depends mosis, cryptococcosis and Pneumocystis carinii pneumo-
on the patient’s body weight. It consists of a single dose of nia. Reactivation and subsequent generalization of preexis-
5 mg/kg body weight at week zero, week two and week six, ting latent tuberculosis has been reported in patients on
and then regularly every eight weeks. infl iximab therapy.
Prolonged intervals between infusions increase the like-
lihood of infl iximab antibodies being formed. Infl iximab is Cardiac effects
administered by intravenous infusion, delivered over a period
of two hours. If there are no infusion reactions, the time can Infl iximab has been associated with exacerbation of preexis-
be shortened to one hour. During the infusion and for one ting heart failure. Infl iximab must therefore not be used in
hour thereafter, the patient must be monitored with emer- patients with NYHA class III–IV heart failure.
gency equipment readily available in case that there is an in-
fusion reaction. Demyelinating diseases
Summary of the evidence As with other TNF- α blockers, isolated cases of demyeli-
nating diseases of the central nervous system have occurred
See long version. in association with infl iximab. Given that multiple sclerosis
may be exacerbated by infl iximab, patients with multiple sc-
Adverse drug reactions / safety lerosis should therefore receive infl iximab therapy only after
carefully weighing risks and benefits.
See Summary of Product Characteristics.
There is a large body of data on the safety of infl iximab Hepatotoxicity
in patients with chronic inflammatory bowel disease and ar-
thritis. While these safety data can generally be extrapolated There have been isolated reports of severe liver damage
to psoriasis vulgaris, prior treatment of psoriasis patients on infl iximab treatment, including fatal liver failure. The-
(UVB, PUVA) may lead to as yet unidentified adverse drug se were associated with hepatitis B infection and occurred
reactions or risks that must be taken into account. within two weeks until more than a year after treatment
initiation. In psoriasis patients, there have only been reports
Infusion reactions of increases in transaminase levels but not of severe liver
damage. Infl iximab should be discontinued if jaundice oc-
Acute infusion reactions are common. These are usually curs or if there is a significant deterioration of liver function
mild and include chills, headache, flushing, nausea, dyspnea tests.
or infi ltration at the infusion site. The likelihood of an in-
Hematological changes
fusion reaction is increased in patients with anti-infl iximab
antibodies. However, anaphylactoid reactions may also occur Leukopenia, neutropenia, thrombocytopenia and pancytope-
irrespective of anti-infl iximab antibodies. Patient monito- nia, some with fatal outcome, have been reported in patients
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Lupus erythematosus-like syndrome Depending on the clinical situation, fewer or more mea-
sures or laboratory tests may be required. They should be
Treatment with infl iximab may be associated with the induc- selected for each patient on an individual basis.
tion of autoantibodies (ANA, anti-dsDNA antibodies) and
Pretreatment measures
the onset of a lupus-like syndrome. In such cases, treatment
should be discontinued immediately. – Rule out acute infection
– Tuberculosis must be definitively ruled out. See long
Prevention/management of ADRs version, section on “Tuberculosis”
When administering the drug, standard emergency equip- – Ensure reliable contraception and rule out pregnancy in
ment should be readily available. women of child-bearing age
If a severe infection occurs, it is important to bear in – Patients should be informed that any infection may run
mind that – given the long time (six months) required for an atypical and more severe clinical course and that
complete elimination – the immunosuppressant effect of in- they should seek medical attention as early as possible
fl iximab can last several weeks after the last dose. Simulta- if an infection is suspected.
neous administration of methotrexate can reduce the forma- Measures during treatment
tion of anti-infl iximab antibodies [10, 11]. – Monitor up to an hour after the infusion
– Monitor for infection; if infection is suspected, treat-
Main contraindications/limitations of use ment should be interrupted, at least temporarily.
Absolute contraindications Posttreatment measures
– NYHA class III–IV heart failure – None
– Known hypersensitivity to mouse proteins
– Active tuberculosis or other serious infections
Table 11 provides an overview of the laboratory tests for
infl iximab therapy recommended by the expert group.
Important relative contraindications Overdose/management of overdose
– Malignancy (except for basal cell carcinoma) and lympho- Single doses of up to 20 mg/kg body weight were tolera-
proliferative disorders, including a history thereof ted without any direct toxic effect. In the case of overdose,
Point in time → Diagnostic tests ↓ Before treatment Before every further infusion
CBC with differential X X
AST, ALT, GGT X X
Hepatitis B serology X
HIV and hepatitis C serology* X
Pregnancy test (urine) X
If infection is suspected, see pretreatment measures
According to the Summary of Product Characteristics, no laboratory tests are currently suggested during treatment with
infliximab. The guideline authors recommend the tests listed above. Depending on the clinical situation, fewer or more
measures or laboratory tests may be required. They should be selected for each patient on an individual basis.
*As indicated by patient history, clinical signs or other laboratory test results.
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the patient should be monitored closely and should receive Table 12 Important adverse reactions associated with
prompt adequate symptomatic treatment. methotrexate.
Very common
Feasibility and costs
Common Nausea, fatigue, vomiting, ele-
See long version. vated transaminases, hair loss
(reversible)
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Point in time → Diagnostic tests ↓ Before treatment After 1 week After 6 weeks Then every 6–12 weeks
Complete blood count 1 X X***** X X
Creatinine X X X X
Liver ultrasound X **
Hepatitis B serology X
Depending on the clinical situation, fewer or more measures or laboratory tests may be required. They should be selected
for each patient on an individual basis.
Table 14 provides an overview of the laboratory tests re- Secukinumab summary table
commended by the expert group for methotrexate therapy. Approval of secukinu- 2015 (moderate to severe psoriasis
mab in Germany vulgaris and psoriatic arthritis)
Overdose/management of overdose Recommended initial 300 mg subcutaneously (2 injec-
dose tions of 150 mg) weekly in the
See long version.
first month, then 300 mg (2 in-
jections of 150 mg) monthly
Feasibility/special considerations/costs
Recommended main- 300 mg subcutaneously monthly
tenance dose (2 injections of 150 mg)
See long version.
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Point in time → Diagnostic tests ↓ Before treatment Week 4 Week 12 Every 3 months
CBC with differential X X X X
AST, ALT, GGT X X X X
Hepatitis B serology X
HIV and hepatitis C serology* X
Pregnancy test (urine) X
If infection is suspected, see pretreatment measures
According to the Summary of Product Characteristics, no laboratory tests are currently suggested during treatment with
secukinumab. The guideline authors recommend the tests listed above. Depending on the clinical situation, fewer or more
measures or laboratory tests may be required. They should be selected for each patient on an individual basis.
*As indicated by patient history, clinical signs or other laboratory test results.
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Guidelines S3 Psoriasis guideline
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