Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Case Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_872_2023

Apremilast-induced rise in intraocular pressure in a chronic plaque psoriasis patient

Department of Dermatology, Venereology, and Leprosy, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
Department of Ophthalmology, All India Institute of Medical Sciences, Deoghar, Jharkhand, India.

Corresponding author: Dr. Ghazal Ahmed, Department of Dermatology, Venereology, and Leprosy, All India Institute of Medical Sciences, Deoghar, Jharkhand, India. ghazal.ahmed4u@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Ahmed G, Das S. Apremilast-induced rise in intraocular pressure in a chronic plaque psoriasis patient. Indian J Dermatol Venereol Leprol. doi: 10.25259/IJDVL_872_2023

Dear Editor,

A 52-year-old man with chronic plaque psoriasis on topical steroids presented with unsatisfactory disease control. He had large, erythematous scaly plaques over the lower limbs and a few small plaques over the back, with on-and-off joint pain and knee joint swelling. The psoriasis area and severity index (PASI) was 13.8. After routine investigations he was started on oral apremilast, the dose being gradually increased to 30 mg twice a day. After about two months, he complained of redness and watering from eyes. There was no associated headache, nor a significant family history. Ocular examination showed conjunctival congestion. Intraocular pressure (IOP) measured using Goldmann Applanation Tonometry was 22.7 and 25.2 mmHg (normal range: 10–21 mmHg) in his right and left eyes, respectively. Cold compresses, carboxymethyl cellulose drops, acyclovir ointment, and dexamethasone-moxifloxacin eye drops were advised which were tapered off in a week. His symptoms subsided within a few days, and he was continued on topical steroids and oral apremilast for psoriasis. However, the relief in ocular symptoms was transient and he presented with similar complaints after three weeks; IOP was still elevated: 25.9 and 26.1 mmHg, and at four weeks, 25.3 and 27.9 mmHg in the right and left eyes, respectively. It raised suspicion that the IOP rise could be drug induced. On further probing, he reported similar eye symptoms in the past when he received apremilast from another practitioner. As the only new drug added and continued was oral apremilast, and symptoms increased with increasing doses of apremilast, it was suspected as the culprit agent and stopped. It led to symptomatic relief within days. His IOP decreased to 23 and 26 mmHg on the 4th day and was normal on the 26th day. The patient has been symptom-free for the last six months after the withdrawal of the apremilast.

The Food and Drug Administration has approved apremilast for plaque psoriasis and psoriatic arthritis management.1 Compared to other systemic agents, this drug has fewer side effects, the most common being gastric upset and the most severe being mood disorders and suicidal tendencies. In a case series, 45 cases of increased tearing, possibly due to apremilast, were noted at standard dosing of 30 mg twice daily.2 Of these, the dechallenge was positive in 10 cases, the rechallenge was positive in three cases and one had a double-positive rechallenge. There are no details of IOP measurement in those cases and it is possible that a apremilast-induced rise in IOP might be implicated. The Naranjo adverse drug reaction probability scale supports the assumption, which scored +9 in our case.3 Although we did not do the rechallenge test, indirectly, increasing the dose from 20 mg to 30 mg, leading to increased symptoms, also reiterates it.

Unilateral glaucoma alerts the wary physician to seek secondary etiologies, which were ruled out in our patient. Thus, the unilateral slight rise in pressure was initially attributed to mechanical error, and the patient was treated empirically in the line of conjunctivitis. However, symptom relapse and increasing IOP trend pointed towards an alternate etiology, leading to our suspicion. Further, evidence for raised IOP following short-duration topical steroids is lacking.4 In our patient, a high-potent topical steroid was applied for < 5% of the body surface area over the thick psoriatic lesions only over the legs. Nevertheless, a suspected topical steroid-induced glaucoma was reported in a patient with chronic use for facial atopic eczema.5 The site’s nearness to the eyes, the high absorption rate of facial skin, and the chronic use might have caused it.

Phosphodiesterase (PDE) inhibitors have shown cross-reactivity within receptor subtypes in different organs, for example, PDE-5 inhibitors may increase blood flow to the ciliary body, increasing IOP.6 Apremilast, a PDE-4 inhibitor, showed some cross-reactivity with other PDE subtypes.7 Thus, there is a good chance that apremilast cross-reacts with PDE receptors in the ciliary body, inhibiting them, leading to vasodilation, increasing ciliary blood flow and thus raising IOP.

To conclude, there might be a temporal association between oral apremilast administration and the rise in IOP, and patients should be educated to seek ophthalmology consultation for new-onset eye discomfort or pain and watering.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of AI-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

References

  1. , . Chronic tearing induced by apremilast. Ann Allergy Asthma Immunol. 2018;121:375.
    [CrossRef] [PubMed] [Google Scholar]
  2. , . Possible association between apremilast therapy and increased tearing. Ophthalmic Plast Reconstr Surg. 2021;37:S31-S32.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , , , et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30:239-45.
    [CrossRef] [PubMed] [Google Scholar]
  4. , . Ocular side-effects of topical corticosteroids: What a dermatologist needs to know. Australas J Dermatol. 2015;56:164-9.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , . Facial eczema and sight-threatening glaucoma. J R Soc Med. 2004;97:485-6.
    [CrossRef] [PubMed] [Google Scholar]
  6. , . Phosphodiesterase inhibitors and the eye. Clin Exp Ophthalmol. 2009;37:514-23.
    [CrossRef] [PubMed] [Google Scholar]
  7. . PDE5 inhibitors – pharmacology and clinical applications 20 years after sildenafil discovery. Br J Pharmacol. 2018;175:2554-65.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]

Fulltext Views
2,001

PDF downloads
1,089
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections