key: cord-1051873-5rm9eme4
authors: Learned, Christine; Alsukait, Sara; Deverapalli, Sandhya; Elliott, Erika; Moody, Katherine; Sobell, Jeffrey; Konnikov, Nellie; Ortega, Melissa; Rosmarin, David
title: Psoriasis adverse events and associated medications as reported in the US Food and Drug Administration’s Adverse Event Reporting System from 2016 to 2021
date: 2022-04-18
journal: JAAD Int
DOI: 10.1016/j.jdin.2022.03.010
sha: 2545a8134769a6caf72fb2af98c637deff44df60
doc_id: 1051873
cord_uid: 5rm9eme4

nan

To the Editor: Medications that have been reported to exacerbate or induce psoriasis include -adrenergic blockers (-blockers), lithium, and antimalarial drugs; however, recent systematic reviews of drugassociated psoriasis are limited, and new causative agents are frequently being reported. 1 We evaluated all reports of psoriasis adverse events in the US Food and Drug Administration's Adverse Event Reporting System from January 1, 2016, through September 30, 2021, excluding medications that have been approved by the US Food and Drug Administration to treat psoriasis or psoriatic arthritis.

The medications most commonly reported for psoriasis adverse events were prednisone, tocilizumab, hydroxychloroquine, and dupilumab, with 674, 513, 437, and 376 reports, respectively (Table  I) . Prednisone was the most commonly reported medication, and it is well known to flare psoriasis upon withdrawal. Previous studies have reported that 31% to 42% of the patients with preexisting psoriasis have an exacerbation after the use of antimalarials. 1 Corresponding to the increased use of hydroxychloroquine for treatment of COVID-19, the highest number of hydroxychloroquine reports by year occurred in 2020. 2 This same trend of a notable increase in reports in 2020 is observed with tocilizumab, a monoclonal antibody, which was reported to improve outcomes in patients with severe COVID-19erelated pneumonia. 3, 4 With 376 reports of psoriasis as an adverse event of dupilumab since its approval in 2017, and association via case reports in the literature, this is an emerging medication that warrants consideration. As the use of PD-1 inhibitors such as nivolumab increases, there may be a subsequent increase in reporting of psoriasis, with 175 cases already noted.

The only -blocker that made it into the top 50 most reported medications was metoprolol, with 97 reports despite the fact that they are one of the most frequently prescribed medications in the United States. 1, 5 More recent studies discussing the mechanism of -blockereinduced psoriasis describe this side effect as ''rare'' overall, despite it being the most frequent type of cutaneous reaction to -blockers. 1, 5 Although lithium has traditionally been associated with drug-induced psoriasis, it had just 20 reports since 2016-a finding that may be secondary to the low frequency of lithium prescriptions in the United States relative to the other medications on the list.

Although it is a useful tool for observing reporting trends, there are several limitations of the US Food and Drug Administration's Adverse Event Reporting System database. These include that rates of occurrence cannot be established from this database, and thus one cannot definitively compare 2 medications within the database; that the presence of a report cannot establish causation between the adverse 207  285  94  39  22  27  674  2  Tocilizumab  108  252  75  33  27  18  513  3  Hydroxychloroquine  103  217  64  29  13  11  437  4  Dupilumab  170  113  69  24  --376  5  Morphine  86  142  29  17  1  4  279  6  Anakinra  62  139  31  11  3  2  248  7  Amlodipine  75  48  37  18  4  13  195  8  Codeine  65  87  17  8  3  -180  9  Human IgG  50  80  29  6  1  11  177  10  Nivolumab  27  31  27  41  32  17 event and reported drug, as the information in the reports is not verified and reflects only the reporter's observations; that the data are subject to reporting bias, for example, medications that are already known to be associated with psoriasis may be less likely to be reported; and that there is the potential for confounders such as underlying disease or concurrent medications that are not controlled for in the study population.

Overall, this study supports the importance of providers considering patients' medications when assessing new or worsening psoriasis, in light of the new availability of medications and changing prescription habits. 

Drug-provoked psoriasis: is it drug induced or drug aggravated?: understanding pathophysiology and clinical relevance

Chloroquine and hydroxychloroquine for the treatment of COVID-19: a systematic review and meta-analysis

Tocilizumab in hospitalized patients with severe COVID-19 pneumonia

Psoriasis as an adverse reaction to biologic agents beyond anti-TNF-therapy

Mechanisms of beta-blocker induced psoriasis, and psoriasis de novo at the cellular level