28463 Aprelimast and psoriasis: Significant hemoglobin A1c reduction and improved insulin resistance independent of changes in body mass index

Abstract

A 46-year-old male with a 25-year history of plaque psoriasis and psoriatic arthritis presented for follow up with uncontrolled disease despite six months of adalimumab. The patient’s past medical history was notable for decompensated cirrhosis due to nonalcoholic steatohepatitis, splenomegaly, esophageal varices, thrombocytopenia, obstructive sleep apnea, obesity, and type 2 diabetes. Given his medical comorbidities, the patient was started on apremilast, reaching goal dose of 30 mg twice daily by four weeks. He achieved total clearance of his psoriasis at four month follow-up. Interestingly, patient’s glucose metabolism and glycemic control had dramatically improved since starting apremilast: hemoglobin A1c dropped from 10.9% at the initiation of therapy to 7.9% at three months and then to 6.6% by six months. His insulin requirement went from 250 units daily to zero by three months. Patient’s BMI, diet, and exercise activity all remained unchanged during this timeframe. No other medication changes were noted except for the addition of low dose propranolol for his history of esophageal varices. The patient continues to remain clear on apremilast after six months with sustained glycemic benefits. This case suggests that apremilast acts as a metabolic modulator of glucose metabolism irrespective of its ability to induce weight loss or reduce BMI. Further studies should investigate the link between proinflammatory chronic conditions, such as psoriasis, and type 2 diabetes. Better understanding of the pathophysiology may help influence therapeutic recommendations, as apremilast could be considered a preferred agent in patients that have psoriasis and concomitant type 2 diabetes or metabolic syndrome.