Systemic Drugs

Systemic medications are available by prescription only. Taken by mouth or by injection, they affect the entire body. Systemic drugs for psoriasis are typically prescribed when topical treatment fails to adequately treat psoriasis. These medications work by suppressing the overactive immune system in psoriatic disease. While typically more effective than topical medications, traditional systemic drugs can have a greater risk of side effects.

List of Medications (Psoriasis)

Click on a medication for additional information.

List of Medications (Psoriatic Arthritis)

Click on a medication for additional information.

Methotrexate

How Does It Work?

Methotrexate can be used to treat psoriasis and the symptoms of psoriatic arthritis. Although the exact mechanism of methotrexate is not known, it is thought to work by regulating the overactive immune system that is present in patients with psoriasis and psoriatic arthritis.

How Is It Used?

Methotrexate is usually prescribed to be taken once per week. It is available as both a pill and an injection.

What Are The Possible Side Effects?

Common side effects of methotrexate treatment include diarrhea, nausea, vomiting, loss of appetite, inflammation of the lips and/or mouth, fatigue, and liver function abnormalities.

Rare side effects of methotrexate include serious reactions such as bone marrow suppression which includes low red blood cell counts or white blood cell counts, as well as decreased platelet counts.  Rarely, it could also potentially cause liver damage, lung damage, or immunosuppression. It can be teratogenic if taken while pregnant (i.e., cause malformations in the unborn child).  To obtain a comprehensive list of all known potential side effects of methotrexate, talk your doctor or pharmacist.

Any Other Important Considerations?

Methotrexate is not safe to take during pregnancy. If you become pregnant while taking methotrexate, contact your doctor immediately.

If you are on this medication, you should not be breastfeeding. If you are pregnant, may be pregnant, planning on becoming pregnant, breastfeeding, or planning to breast feed, speak with your prescriber before starting this medication.

While on this medication or if you just came off of this medication, if applicable, you should be on at least two forms of reliable birth control to prevent pregnancy as the drug can cause harm to an unborn baby. Make sure to discuss this with your prescriber.

Alcohol consumption is not recommended while taking methotrexate due to the risk of liver toxicity.

Since methotrexate is associated with rare, serious side effects, close monitoring by your doctor is recommended.

What Medications Interact With This Treatment?

Some medications that may interact with methotrexate include acitretin, cyclosporine, furosemide, NSAIDs (e.g., ibuprofen, naproxen), and trimethoprim/sulfamethoxazole. For a complete list of medications that may interact with methotrexate and to understand how a potential drug interaction should be managed, talk to your doctor or pharmacist.

What Provinces and Territories List It On Formulary?

British Columbia: Yes
Alberta: Yes
Saskatchewan: Yes
Manitoba: Yes
Ontario: Yes
Quebec: Yes
New Brunswick: Yes
Nova Scotia: Yes
Prince Edward Island: Yes
Newfoundland and Labrador: Yes
Nunavut: Yes
Northwest Territories: Yes
Yukon: Yes

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Cyclosporine

How Does It Work?

Cyclosporine is an oral medication often used in patients with liver, lung, or heart transplants. It works to treat psoriasis by regulating the immune system.

How Is It Used?

Cyclosporine is an oral medication dosed based on weight. The typical starting dose of cyclosporine is 2.5 mg/kg/day in two divided doses. The maximum dose of cyclosporine is 4 mg/kg/day.

What Are The Possible Side Effects?

It should be noted that because of the risk of toxicity, cyclosporine therapy should be limited to one year.  Common side effects of cyclosporine include abdominal pain, diarrhea, nausea, headache, increased blood pressure, and tremor. Due to the risk of rarer, more serious side effects such as potential liver or kidney damage, it is important to be monitored regularly by your doctor when taking cyclosporine. To obtain a comprehensive list of all known potential side effects of cyclosporine, talk your doctor or pharmacist.

Any Other Important Considerations?

Grapefruit juice can increase the amount of cyclosporine in the blood. Grapefruit juice should be avoided if you are taking cyclosporine.

What Medications Interact With This Treatment?

Some medications that may interact with cyclosporine include amiodarone, atorvastatin, carbamazepine, carvedilol, cochicine, dabigatran, echinacea, edoxaban, eplerenone, fluvastatin, lovastatin, methotrexate, mifepristone, NSAIDs (e.g., ibuprofen, naproxen), orlistat, pravastatin, repaglinide, ritonavir, rosuvastatin, simvastatin, and St. John’s wort.

For a complete list of medications that may interact with cyclosporine and to understand how a potential drug interaction should be managed, talk to your doctor or pharmacist. Before starting any new medications, ask a doctor or pharmacist if it is ok to take with cyclosporine.

What Provinces and Territories List It On Formulary?

British Columbia: Yes – S/A for plaque psoriasis
Alberta: Yes – S/A for plaque psoriasis
Saskatchewan: Yes – S/A for plaque psoriasis
Manitoba: Yes – S/A for plaque psoriasis
Ontario: Yes – S/A for plaque psoriasis
Quebec: Yes
New Brunswick: Yes
Nova Scotia: Yes
Prince Edward Island: Yes
Newfoundland and Labrador: Yes
Nunavut: Yes – S/A for plaque psoriasis
Northwest Territories: Yes – S/A for plaque psoriasis
Yukon: Yes

More information is available on S/A (special access) at Special Access / Limited Use Designation Drugs.

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Acitretin (Soriatane®)

How Does It Work?

The exact mechanism of acitretin is unknown. It is thought to play a role in the multiplication of skin cells, and it may also have some immune-modulatory properties (i.e., regulates the immune system).

How Is It Used?

Acitretin is an oral medication and is typically taken with food in doses ranging from 25 to 50 mg per day.

What Are The Possible Side Effects?

Acitretin is teratogenic and should not be used in women of childbearing potential unless they plan to refrain from pregnancy for at least three years after discontinuing the drug. Common side effects of acitretin include hair loss, dry lips, dry skin, dry eyes, dry mouth, itchiness, joint pain, abnormal sensations such as tingling, and nose bleeds. Acitretin can also cause pancreatitis. If you notice depressive symptoms, have suicidal thoughts, or are experiencing nausea, vomiting, and headache while taking acitretin, it is important to consult your doctor. To obtain a comprehensive list of all known potential side effects of acitretin, talk your doctor or pharmacist.

Any Other Important Considerations?

Full improvement may not be seen for a few months, and temporary worsening of psoriasis may be seen initially.

Acitretin is a teratogen and increases the risk of significant birth defects. When treated with acitretin, two forms of reliable contraception to avoid pregnancy should be used starting one month prior to acitretin therapy through three years post-therapy.

Female patients of childbearing age are advised not to drink alcohol during acitretin therapy and for at least two months post-treatment, as alcohol can prolong the duration that acitretin has the ability to cause birth defects.

In general, treatment with acitretin should be discontinued when psoriasis sufficiently clears. Relapses of psoriasis may require acitretin to be restarted.

What Medications Interact With This Treatment?

Tetracycline antibiotics should not be taken while on acitretin therapy.

For a complete list of medications that may interact with acitretin and to understand how a potential drug interaction should be managed, talk to your doctor or pharmacist. Before starting any new medications, ask a doctor or pharmacist if it is ok to take with acitretin.

What Provinces and Territories List It On Formulary?

British Columbia: Yes
Alberta: Yes
Saskatchewan: Yes – S/A for plaque psoriasis
Manitoba: Yes
Ontario: Yes
Quebec: Yes
New Brunswick: Yes
Nova Scotia: Yes
Prince Edward Island: Yes – S/A for plaque psoriasis
Newfoundland and Labrador: Yes
Nunavut: Yes
Northwest Territories: Yes
Yukon: Yes – S/A for plaque psoriasis

More information is available on S/A (special access) at Special Access / Limited Use Designation Drugs.

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Apremilast (Otezla®)

How Does It Work?

Apremilast is a drug that regulates the immune system by decreasing inflammatory molecules that are associated with psoriasis and psoriatic arthritis.

How Is It Used?

Apremilast is an oral medication that is usually prescribed to be taken twice daily. When starting apremilast, your doctor may recommend starting at a lower dose and then increasing the dose each day until the recommended dose is reached. This is done to reduce the chance of side effects. Initial improvement of psoriasis may be noted as soon as the first few weeks of treatment.

What Are The Possible Side Effects?

Common side effects of apremilast include diarrhea, nausea, headache, and upper respiratory tract infections. It is important to contact your physician if you experience new or worsening depression, suicidal ideation, or other mood changes while on apremilast. To obtain a comprehensive list of all known potential side effects of apremilast, talk your doctor or pharmacist.

Any Other Important Considerations?

N/A

What Medications Interact With This Treatment?

Some medications can cause apremilast to be removed from the body faster, potentially reducing its effectiveness. Your physician or pharmacist can help you determine if you are on a medication that can reduce the effectiveness of apremilast.

St. John’s Wort, an over-the-counter natural health product, can reduce the effectiveness of apremilast. Use of St. John’s Wort is not recommended in patients taking apremilast.

What Provinces and Territories List It On Formulary?

British Columbia: No
Alberta: No
Saskatchewan: No
Manitoba: No
Ontario: No
Quebec: Yes – S/A for plaque psoriasis
New Brunswick: No
Nova Scotia: No
Prince Edward Island: No
Newfoundland and Labrador: No
Nunavut: No
Northwest Territories: No
Yukon: No

More information is available on S/A (special access) at Special Access / Limited Use Designation Drugs.

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Call 1-844-ez-Start (1-844-397-8278) for information.

Leflunomide (Arava®)

How Does It Work?

Leflunomide is approved for use in rheumatoid arthritis, but it can be used for the treatment of psoriatic arthritis off-label. It works by suppressing the overactive immune system in psoriatic arthritis.

How Is It Used?

Leflunomide is a pill that can be taken with or without food. It works best if you take it at the same time every day. Swallow the tablet whole with a glass of water.

Leflunomide is NOT recommended for use in patients younger than 18 years of age. There is not enough experience of its use in this population.

It may take about 8-12 weeks until you start to feel an improvement in your symptoms.

This drug tends to stay in your body for a prolonged period of time even after you stop taking it.

What Are The Possible Side Effects?

Potential side effects of leflunomide include headache, hair loss, skin rash, diarrhea, nausea, abdominal pain, dizziness, and high blood pressure. To obtain a comprehensive list of all known potential side effects of leflunomide, talk your doctor or pharmacist.

Any Other Important Considerations?

This drug should not be taken if you are pregnant. If you are on this medication, you should not be breastfeeding. If you are pregnant, may be pregnant, planning on becoming pregnant, breastfeeding, or planning to breast feed, speak with your doctor before starting this medication.

While on this medication or if you just came off of this medication, if applicable, you should be on at least two forms of reliable birth control to prevent pregnancy as the drug can cause harm to an unborn baby. Make sure to discuss this with your doctor. If you become pregnant while on this medication, call your doctor immediately.

Once you stop taking leflunomide, it is generally recommended that you wait a period of at least 2 years before trying to get pregnant. You will need to have blood tests showing that your body is free of leflunomide before you stop taking birth control. There are options available to speed up the elimination of this drug from your body if you would like to get pregnant sooner. Speak with your doctor.

If you are a male and have sex with a female who could get pregnant or you wish to father a biological child, speak with your doctor. In general, exposures that fathers have are unlikely to increase risks to a pregnancy. However, the label recommends that once you start taking leflunomide, you should take every precaution to avoid getting your partner pregnant, and you should use a reliable form of birth control that is recommended by your doctor. It is recommended that you wait at least 2 years before trying to father a biological child. You will need to have blood tests showing that your body is free of leflunomide before you start trying to father a biological child. There are options available to speed up the elimination of this drug from your body if you would like to try sooner. Speak with your physician.

If you have kidney or liver disease, this drug may accumulate in your body and the risk of toxic effects may be increased. Please let your physician, nurse practitioner, or pharmacist know so that the dose can be adjusted accordingly or other options can be explored if necessary.

Your physician may order regular bloodwork for you. Make sure to get your bloodwork checked as advised.

It is important you keep taking this drug as instructed by your doctor even if you are no longer experiencing the symptoms of your psoriatic arthritis.

You should avoid drinking alcohol while taking this medication as it can increase the risk of liver damage.

What Medications Interact With This Treatment?

It is recommended that you do not receive any live vaccines while on leflunomide or within 6 months after stopping the medication.

Warfarin may interact with this medication. You may need to get your INR levels checked more regularly. Speak with your doctor.

Some examples of medications that interact with leflunomide include activated charcoal, azathioprine, cholestyramine, duloxetine, methotrexate, phenytoin, warfarin, certain diabetic medications, certain antibiotics, cholesterol medications, anti-inflammatory medications and certain chemotherapeutic agents. This list is not exhaustive – make sure to check with your doctor or pharmacist before taking any over-the-counter medications, natural health products, or prescribed medications.

What Provinces and Territories List It On Formulary?

British Columbia: Yes – S/A for psoriatic arthritis
Alberta: No
Saskatchewan: Yes – S/A for psoriatic arthritis
Manitoba: No
Ontario: Yes
Quebec: Yes
New Brunswick: Yes
Nova Scotia: Yes
Prince Edward Island: Yes
Newfoundland and Labrador: Yes
Nunavut: Yes
Northwest Territories: Yes
Yukon: No

More information is available on S/A (special access) at Special Access / Limited Use Designation Drugs.

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Sulfasalazine

How Does It Work?

This medication was originally developed to treat inflammatory bowel diseases. Sulfasalazine is sometimes used to treat psoriatic arthritis. About 1/3 of psoriatic arthritis patients respond to sulfasalazine within 8-12 weeks. It works by suppressing the overactive immune system in psoriatic arthritis. This medication may also have anti-inflammatory effects.

How Is It Used?

It comes in regular tablet or long-acting tablets. Sulfasalazine should be taken after meals. Long-acting tablets should be swallowed whole without chewing, breaking, or crushing.

What Are The Possible Side Effects?

Potential side effects of sulfasalazine include headache, skin rash, nausea, abdominal pain, vomiting, and weight loss. To obtain a comprehensive list of all known potential side effects of sulfasalazine, talk your doctor or pharmacist.

Any Other Important Considerations?

This is a sulfa drug. If you are allergic to sulfa, you may also be allergic to this medication.

It is important that you have your bloodwork and urine checked as directed by your doctor. This drug can also affect the results of certain tests, and you should notify healthcare providers that you take this medication.

This drug can cause certain problems with sperm in males and affect the patient’s ability to father a biological child. This usually resolves once the drug is stopped. Speak with your doctor.

If you are pregnant, planning on getting pregnant, breastfeeding, or planning on breastfeeding, speak with your doctor regarding the benefits and risks of taking this medication.

If you have kidney or liver disease, this drug may accumulate in your body and the risk of toxic effects may be increased. Please let your physician, nurse practitioner, or pharmacist know so that the dose can be adjusted accordingly or other options can be explored if necessary.

What Medications Interact With This Treatment?

Some examples of medications which interact with sulfasalazine include antibiotics, Warfarin or other blood thinners (i.e., rivaroxaban aka Xarelto), antidiabetic medications, Digoxin, Phenytoin. For a complete list of medications that may interact with sulfasalazine and to understand how a potential drug interaction should be managed, talk to your doctor or pharmacist. Before starting any new medications, ask a doctor or pharmacist if it is ok to take with sulfasalazine.

What Provinces and Territories List It On Formulary?

British Columbia: Yes
Alberta: Yes
Saskatchewan: Yes
Manitoba: Yes
Ontario: Yes
Quebec: Yes
New Brunswick: Yes
Nova Scotia: Yes
Prince Edward Island: Yes
Newfoundland and Labrador: Yes
Nunavut: Yes
Northwest Territories: Yes
Yukon: Yes

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

How Does It Work?

NSAID stands for non-steroidal anti-inflammatory drugs.

Examples of NSAIDs include acetylsalicylic acid (Aspirin), ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), meloxicam, and diclofenac (Voltaren, Arthrotec).

NSAIDs are medicines that relieve pain and reduce inflammation by stopping a chemical process in the body that leads to inflammation. NSAIDs are also used to treat fever.

How Are They Used?

NSAIDs come in a variety of forms including oral forms, suppositories, topical, and injectable forms.

Some oral NSAIDs are available over-the-counter, whereas others are available by prescription only. Some of the over-the-counter NSAIDs are available by prescription only at certain strengths.

Pill forms should be taken with food to lessen stomach upset.

What Are The Possible Side Effects?

The most common potential side effects from NSAIDs are related to the stomach. Side effects may range from discomfort, to more rarely gastrointestinal bleeding, perforation, or ulceration. Less frequently, NSAIDs can have side effects related to the heart, kidneys, and skin. To obtain a comprehensive list of all known potential side effects of a specific NSAID, talk your doctor or pharmacist.

Any Other Important Considerations?

You should discuss whether or not it is safe for you to take NSAIDs with your doctor, primary care provider, or pharmacist if you have:

  • An ulcer in your stomach or intestine or if you have ever had bleeding from the gut
  • Heart disease (i.e., heart failure) or history of a stroke
  • Asthma or other lung conditions
  • Kidney disease
  • Liver disease
  • High blood pressure
  • Disorders that increase the risk of bleeding
  • Plans for a surgery

If you are pregnant, NSAIDs should be avoided during the last 3 months of pregnancy. Check with your healthcare provider if you are breastfeeding or planning to breastfeed.

Make sure to check with your physician, nurse practitioner, or a pharmacist regarding the maximum daily dose of an NSAID.

Acetaminophen (aka Tylenol) is not an NSAID, but it can be added on for pain relief. However, it does not have any effect on inflammation.

What Medications Interact With This Treatment?

Some examples of medications which interact with NSAIDs include diuretics (i.e., furosemide aka Lasix), blood pressure medications (i.e., beta blockers, hydrochlorothiazide), warfarin and other blood thinners (i.e., rivaroxaban aka Xarelto), lithium, cyclosporine, and certain antibiotics like trimethoprim-sulfamethoxazole (e.g., Septra). For a complete list of medications that may interact with specific NSAIDs and to understand how a potential drug interaction should be managed, talk to your doctor or pharmacist. Before starting any new medications, ask a doctor or pharmacist if it is ok to take with NSAIDs.

What Provinces and Territories List It On Formulary?

There are many different NSAIDs, some of which are over-the-counter, and coverage may vary based on the specific drug.

Celecoxib

How Does It Work?

Celecoxib is a type of NSAID (nonsteroidal anti-inflammatory drug) that has been shown to be less hard on the stomach compared to other NSAIDs according to some studies. It is used to relieve pain and reduce inflammation by stopping a chemical process in the body that leads to inflammation.

How Is It Used?

Celecoxib comes in capsule form that can be taken orally. It is recommended to take celecoxib with food.

What Are The Possible Side Effects?

The most common potential side effects from celecoxib are related to the stomach. Celecoxib is thought to have less gastrointestinal side effects than other NSAIDs. Side effects may range from discomfort, to more rarely gastrointestinal bleeding, perforation, or ulceration. Less frequently, celecoxib can have side effects related to the heart, kidneys, and skin. To obtain a comprehensive list of all known potential side effects of celecoxib, talk your doctor or pharmacist.

Any Other Important Considerations?

Celecoxib is not necessarily superior to regular NSAIDs in terms of effectiveness. It can be more costly than regular NSAIDs. It also has similar risks as NSAIDs with regards to risk of kidney disease or heart disease. Speak with your doctor about the benefits and risks of taking celecoxib.

Celecoxib should not be used in patients who are allergic to sulfa drugs as it has a similar chemical structure to sulfa drugs.

What Medications Interact With This Treatment?

Some examples of medications which interact with celecoxib include diuretics (i.e., furosemide aka Lasix), blood pressure medications (i.e., beta blockers, hydrochlorothiazide), warfarin and other blood thinners (i.e., rivaroxaban aka Xarelto), lithium, cyclosporine, and certain antibiotics like trimethoprim-sulfamethoxazole (e.g., Septra). For a complete list of medications that may interact with specific celecoxib and to understand how a potential drug interaction should be managed, talk to your doctor or pharmacist. Before starting any new medications, ask a doctor or pharmacist if it is ok to take with celecoxib.

What Provinces and Territories List It On Formulary?

British Columbia: Yes – S/A for psoriatic arthritis
Alberta: Yes – S/A for psoriatic arthritis
Saskatchewan: Yes
Manitoba: Yes
Ontario: No
Quebec: Yes
New Brunswick: Yes
Nova Scotia: Yes
Prince Edward Island: Yes
Newfoundland and Labrador: Yes
Nunavut: Yes
Northwest Territories: Yes
Yukon: Yes

More information is available on S/A (special access) at Special Access / Limited Use Designation Drugs.

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Tofacitinib (Xeljanz®) (JAK inhibitor)

How Does It Work?

Tofacitinib is a medication that targets the overactive immune system in psoriatic arthritis. Tofacitinib works by inhibiting janus kinase enzymes, which are involved in immune system activity.

How Is It Used?

Tofacitinib is a medication taken by mouth. It is available as a 5 mg tablet taken twice a day or as an 11 mg tablet taken once a day.

What Are The Possible Side Effects?

The most common side effects of tofacitinib include bronchitis, diarrhea, dyspepsia, headache, nasopharyngitis, and nausea. To obtain a comprehensive list of all known potential side effects of tofacitinib, talk your doctor or pharmacist.

Any Other Important Considerations?

Use of tofacitinib is not recommended in patients with severe liver problems. Dosage reduction may be required in patients with liver or kidney impairment. Tofacitinib is also contraindicated in people who are pregnant and breastfeeding.

Lymphoma and other malignancies, serious infections and thrombosis have been reported in patients taking tofacitinib. Discuss with your health care provider what this may mean for you and the relative risk versus the potential benefits of tofacitinib.

An increased risk of adverse effects with tofacitinib has been noted when used in patients over the age of 65 and in Asian patients.

Some vaccinations, known as live vaccinations, should be avoided while on tofacitinib. Before receiving a vaccination, ask your healthcare provider if the vaccine is ok to receive while on tofacitinib.

What Medications Interact With This Treatment?

Some medications that may interact with tofacitinib include antiarrythmics beta-blockers, calcium channel blockers, cholinesterase inhibitors, HIRV protease inhibitors, rifampin, ketoclonozole, and fluconazole. It is not recommended to take tofacitinib with drugs such as azathioprine, cyclosporine, biologics or baricitini.

For a complete list of medications that may interact with tofacitinib and to understand how a potential drug interaction should be managed, talk to your doctor or pharmacist.

What Provinces and Territories List It On Formulary?

British Columbia: No
Alberta: No
Saskatchewan: No
Manitoba: No
Ontario: No
Quebec: No
New Brunswick: No
Nova Scotia: No
Prince Edward Island: No
Newfoundland and Labrador: No
Nunavut: No
Northwest Territories: No
Yukon: No

This site is updated regularly; however this is information is subject to change.  For the most up-to-date information regarding your specific province / territory click here.

Last updated July 24, 2020.

Disclaimer

This Site was designed for educational purposes only and not for the purpose of rendering medical advice. Individual variances in psoriasis cases require the consultation of a physician to make sound medical decisions. The information presented on this website is not intended to replace the counsel of your physician. It is important to see your doctor before altering anything in your treatment plan. The Canadian Psoriasis Network does not endorse any medications, products, equipment or treatments for psoriasis and psoriatic arthritis. Any of the information contained within the Canadian Psoriasis Network’s Site is not presented as a substitute for informed medical advice. Visitors to this site should not engage in self-diagnosis nor act on information contained in the Site without seeking specific advice on the particular matters which are of concern to them from qualified health professionals and advisors. Some of the information contained in the Site has been provided from external sources. While efforts have been made to ensure the accuracy, currency, and reliability of the content, the Canadian Psoriasis Network accepts no responsibility in that regard. Please refer to our Terms of Use for further details.

This resource was made possible through support from:

Abbvie
Pfizer
Janssen
Bausch
 
LEO Pharma
Novartis
Amgen

 
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