Apremilast

Apremilast is indicated in the United States for the treatment of adults with active psoriatic arthritis, people with plaque psoriasis who are candidates for phototherapy or systemic therapy, and adults with oral ulcers associated with Behçet's disease.

In the European Union, apremilast alone or in combination with disease-modifying antirheumatic drugs (DMARDs), is indicated for the treatment of active psoriatic arthritis (PsA) in adults who have had an inadequate response or who have been intolerant to a prior DMARD therapy. It is also indicated for the treatment of moderate to severe chronic plaque psoriasis in adults who failed to respond to, have a contraindication to, or are intolerant of other systemic therapies, including cyclosporine, methotrexate, or psoralen and ultraviolet-A light.

In the European Union, the drug is contraindicated during pregnancy because mice and monkeys receiving very high doses of apremilast have been observed to suffer miscarriages and other pregnancy problems.{{cite book |title=Austria-Codex| veditors = Haberfeld H |publisher=Österreichischer Apothekerverlag |location=Vienna |year=2015 |language=de}} In the US, it may be used for pregnant women "if the potential benefit justifies the potential risk to the fetus".{{cite web | title=Apremilast (Otezla) Use During Pregnancy | website=Drugs.com | date=27 September 2019 | url=https://www.drugs.com/pregnancy/apremilast.html | access-date=19 April 2020}}

Diarrhea occurs in about 25% of people taking apremilast. Severe gastrointestinal symptoms, when they occur, typically start within the first few weeks of treatment.{{cite journal | vauthors = Kavanaugh A, Mease PJ, Gomez-Reino JJ, Adebajo AO, Wollenhaupt J, Gladman DD, Hochfeld M, Teng LL, Schett G, Lespessailles E, Hall S | title = Longterm (52-week) results of a phase III randomized, controlled trial of apremilast in patients with psoriatic arthritis | journal = The Journal of Rheumatology | volume = 42 | issue = 3 | pages = 479–488 | date = March 2015 | pmid = 25593233 | doi = 10.3899/jrheum.140647 | doi-access = free }}{{cite journal | vauthors = Stein Gold L, Bagel J, Lebwohl M, Jackson JM, Chen R, Goncalves J, Levi E, Duffin KC | title = Efficacy and Safety of Apremilast in Systemic- and Biologic-Naive Patients With Moderate Plaque Psoriasis: 52-Week Results of UNVEIL | journal = Journal of Drugs in Dermatology | volume = 17 | issue = 2 | pages = 221–228 | date = February 2018 | pmid = 29462231 }}

Worsening depression, suicidal thoughts, and other mood changes may occur with apremilast.{{cite web | title=Otezla- apremilast tablet, film coated Otezla- apremilast kit | website=DailyMed | date=26 February 2020 | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f6b1f516-4972-4d82-bced-113e47b41cc5 | access-date=19 April 2020}}

Weight loss has been associated with apremilast. Reports from clinical studies indicated a 5 to 10% decrease in body weight in 10% of patients taking apremilast (compared to 3.3% of patients taking placebo).

Common, usually mild to moderate adverse effects associated with apremilast include headache, back pain, nausea, diarrhea, fatigue, nasopharyngitis, and upper respiratory tract infections.{{cite journal | vauthors = Mease PJ, Armstrong AW | title = Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis | journal = Drugs | volume = 74 | issue = 4 | pages = 423–441 | date = March 2014 | pmid = 24566842 | pmc = 3958815 | doi = 10.1007/s40265-014-0191-y }}

Concurrent use of strong cytochrome P450 enzyme inducers has been shown to decrease exposure of apremilast and can result in reduced or loss of efficacy of apremilast. Using it simultaneously with strong P450 enzyme inducers, including rifampicin, phenobarbital, carbamazepine, phenytoin, and St. John's wort is not recommended.{{cite web|title=Otezla Product Monograph|url=https://pdf.hres.ca/dpd_pm/00054839.PDF |access-date=3 April 2015|archive-url=https://web.archive.org/web/20150407204756/http://www.celgenecanada.net/pdfs/Otezla_Product_Monograph_English_Version.pdf|archive-date=7 April 2015|url-status=live}}

Apremilast is a small-molecule inhibitor of PDE4, an enzyme that breaks down cyclic adenosine monophosphate (cAMP). In inflammatory cells, PDE4 is the dominant enzyme responsible for this reaction. The resulting increase in cAMP levels down-regulates expression of a number of pro-inflammatory factors such as tumor necrosis factor alpha (TNFα), interleukin 17, interleukin 23, and many others, and up-regulates the anti-inflammatory interleukin 10. In ex vivo models of arthritis, IL-12/IL-23p40 was specifically identified as a downstream target of apremilast.{{cite journal | vauthors = Kragstrup TW, Adams M, Lomholt S, Nielsen MA, Heftdal LD, Schafer P, Deleuran B | title = IL-12/IL-23p40 identified as a downstream target of apremilast in ex vivo models of arthritis | journal = Therapeutic Advances in Musculoskeletal Disease | volume = 11 | pages = 1759720X19828669 | year = 2019 | pmid = 30833991 | pmc = 6391542 | doi = 10.1177/1759720X19828669 }} The importance of these individual factors for the clinical effect of apremilast is not clear.

Apremilast is absorbed well from the gut (73%), independently of food intake, and reaches peak blood plasma concentrations after 2.5 hours. Plasma protein binding is 68%. It is metabolised in the liver, mainly via the enzyme CYP3A4, but to a minor extent via CYP1A2 and CYP2A6. The main metabolite is O-desmethylapremilast glucuronide.

Its half-life is 6–9 hours. The substance is eliminated through the kidney (58%) and feces (39%), mainly in form of its metabolites. Only 3% of the original substance is found in the urine, and 7% in the feces.

Apremilast is a phthalimide derivative. It is a white to pale yellow, nonhygroscopic powder that is practically insoluble in water and buffer solutions in a wide pH range, but is soluble in lipophilic solvents such as acetone, acetonitrile, butanone, dichloromethane, and tetrahydrofuran.{{cite web|url=http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Public_assessment_report/human/003746/WC500182629.pdf|title=Assessment report for Otezla|publisher=EMA|date=20 November 2014|access-date=22 January 2016|archive-date=17 June 2018|archive-url=https://web.archive.org/web/20180617204050/http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Public_assessment_report/human/003746/WC500182629.pdf|url-status=dead}}

In vitro, apremilast reduces PDE4 activity, leading to an increase in cyclic-adenosine monophosphate (cAMP) concentrations in immune and nonimmune cell types, partially inhibiting the production of many pro-inflammatory cytokines, such as TNF-α, IFN-γ IL-2, IL-12, and IL-23 and elevating the production of the anti-inflammatory cytokine IL-10.{{cite journal | vauthors = Schafer P | title = Apremilast mechanism of action and application to psoriasis and psoriatic arthritis | journal = Biochemical Pharmacology | volume = 83 | issue = 12 | pages = 1583–1590 | date = June 2012 | pmid = 22257911 | doi = 10.1016/j.bcp.2012.01.001 }}{{cite journal | vauthors = Schafer PH, Parton A, Gandhi AK, Capone L, Adams M, Wu L, Bartlett JB, Loveland MA, Gilhar A, Cheung YF, Baillie GS, Houslay MD, Man HW, Muller GW, Stirling DI | title = Apremilast, a cAMP phosphodiesterase-4 inhibitor, demonstrates anti-inflammatory activity in vitro and in a model of psoriasis | journal = British Journal of Pharmacology | volume = 159 | issue = 4 | pages = 842–855 | date = February 2010 | pmid = 20050849 | pmc = 2829210 | doi = 10.1111/j.1476-5381.2009.00559.x }} The inhibition potency of apremilast in TNF-α production is similar to lenalidomide.{{cite book|vauthors=Michelli ML|title=Liver cirrhosis : causes, diagnosis, and treatment|publisher=Nova Biomedical Books|location=New York|isbn=978-1-61209-248-5|url=http://www.uaeh.edu.mx/sistema_investigacion/funciones/bajarArchivo_web.php?producto=4456&archivo=cirrosis_cap.pdf&fb_source=message|year=2011|access-date=26 July 2018|archive-date=4 March 2016|archive-url=https://web.archive.org/web/20160304090053/http://www.uaeh.edu.mx/sistema_investigacion/funciones/bajarArchivo_web.php?producto=4456&archivo=cirrosis_cap.pdf&fb_source=message|url-status=dead}}

Celgene reported seven kinds of crystal forms — A, B, C, D, E, F, and G — and thought the crystal form B was the most thermodynamically stable anhydrous form. However, Utopharm reported another more thermodynamically stable anhydrous crystal form II than the crystal form B.{{cite web|url=http://www.utopharm.com/youchuo_en/news_sub.aspx?id=61 |title=A novel stable and non-solvate crystal form II on Apremilast and processes for the preparation thereof |publisher=Utopharm |date=18 April 2015 |url-status=dead |archive-url=https://web.archive.org/web/20150531020846/http://www.utopharm.com/youchuo_en/news_sub.aspx?id=61 |archive-date=31 May 2015 }}

Apremilast was approved by the US Food and Drug Administration (FDA) in 2014, for treatment of adults with active psoriatic arthritis and moderate to severe plaque psoriasis, and approved in 2019, for oral ulcers associated with Behçet's disease.[http://ir.celgene.com/releasedetail.cfm?releaseid=872240 "Oral Otezla (apremilast) Approved by the U.S. Food and Drug Administration for the Treatment of Patients with Moderate to Severe Plaque Psoriasis"] (Press release). Celgene Corporation. 23 September 2014. Retrieved 29 October 2014.{{cite press release | title=FDA approves Otezla to treat psoriatic arthritis | website=U.S. Food and Drug Administration (FDA) | date=21 March 2014 | url=https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm390091.htm | archive-url=https://web.archive.org/web/20170213211338/https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm390091.htm | archive-date=13 February 2017 | url-status=dead | access-date=19 April 2020}} {{PD-notice}}{{Cite press release | url=https://ir.celgene.com/press-releases-archive/press-release-details/2019/FDA-Approves-OTEZLA-apremilast-for-the-Treatment-of-Oral-Ulcers-Associated-with-Behets-Disease/ |title=FDA Approves Otezla (apremilast) for the Treatment of Oral Ulcers Associated with Behçet's Disease |website=Celgene Corporation | date=19 July 2019 | access-date=11 November 2019 | archive-url=https://web.archive.org/web/20200420032909/https://ir.celgene.com/press-releases-archive/press-release-details/2019/FDA-Approves-OTEZLA-apremilast-for-the-Treatment-of-Oral-Ulcers-Associated-with-Behets-Disease/ | archive-date=20 April 2020 | url-status=live }} Apremilast is taken by mouth.{{cite web | title=Apremilast for the Treatment of Psoriatic Arthritis | website=American College of Rheumatology | date=14 June 2014 | url=http://www.rheumatology.org/Publications/Hotline/Apremilast_for_the_Treatment_of_Psoriatic_Arthritis/ | archive-url=https://web.archive.org/web/20150221195556/http://www.rheumatology.org/Publications/Hotline/Apremilast_for_the_Treatment_of_Psoriatic_Arthritis/ | archive-date=21 February 2015 | url-status=dead | access-date=29 October 2014}}

Apremilast is available in the US, but is dispensed only through a network of specialty pharmacies. The estimated wholesale price is {{US$|22,500}} for a year of treatment. In Austria, a year of treatment costs health insurances about {{Euro|11,000}} as of 2018.{{cite book|title=Warenverzeichnis|volume=I|page=92|date=May 2018|publisher=Österreichischer Apothekerverlag|location=Vienna|language=de}} Celgene made Otezla available in the UK in 2015.{{cite web|url=https://www.zenopa.com/news/801777078/celgene-launches-new-psoriasis-drug-otezla-in-uk|title=Celgene launches new psoriasis drug Otezla in UK|date=24 May 2021|access-date=24 May 2021|archive-date=24 May 2021|archive-url=https://web.archive.org/web/20210524192944/https://www.zenopa.com/news/801777078/celgene-launches-new-psoriasis-drug-otezla-in-uk|url-status=dead}}

In 2019, Amgen acquired Otezla from Celgene for $13.4 billion.{{cite press release | title=Amgen To Acquire Otezla For $13.4 Billion in Cash or Approximately $11.2 Billion Net of Anticipated Future Cash Tax Benefits | website=Amgen, Inc | date=26 August 2019 | url=https://www.amgen.com/newsroom/press-releases/2019/08/amgen-to-acquire-otezla-for-134-billion-in-cash-or-approximately-112-billion-net-of-anticipated-future-cash-tax-benefits | access-date=19 April 2020 | archive-date=7 October 2021 | archive-url=https://web.archive.org/web/20211007133537/https://www.amgen.com/newsroom/press-releases/2019/08/amgen-to-acquire-otezla-for-134-billion-in-cash-or-approximately-112-billion-net-of-anticipated-future-cash-tax-benefits | url-status=live }}{{cite press release | title=Amgen Completes Acquisition Of Otezla (apremilast) | website=Amgen | date=21 November 2019 | url=https://www.amgen.com/newsroom/press-releases/2019/11/amgen-completes-acquisition-of-otezla-apremilast | access-date=23 February 2024}}

In 2020, Otezla generated $2.2 billion for Amgen.{{cite press release | title=Amgen Reports Fourth Quarter And Full Year 2020 Financial Results | website=Amgen, Inc | date=2 February 2021 | url=https://investors.amgen.com/news-releases/news-release-details/amgen-reports-fourth-quarter-and-full-year-2020-financial | access-date=2 February 2021}}

Apremilast was listed on the PBS in Australia in January 2021, for chronic plaque psoriasis.{{cite web|url=https://m.pbs.gov.au/industry/listing/participants/public-release-docs/2023-09/apremilast-24-month-review-DUSC-PRD-2023-09.html | title=PBS Drug utilisation sub committee report September 2023 | access-date=16 October 2024}} As of October 2024, the cost to the Australian government for a year of treatment is about $8500, and the cost to consumer is about $400.{{cite web|url=https://www.pbs.gov.au/medicine/item/12223H | title= PBS listing for Apremilast | access-date=16 October 2024}}

Apremilast was approved for use in the European Union in January 2015.{{cite web | title=Otezla EPAR | website=European Medicines Agency (EMA) | date=17 September 2018 | url=https://www.ema.europa.eu/en/medicines/human/EPAR/otezla | access-date=19 April 2020}} {{PD-notice}}

Generic versions of the medication are available in Canada.{{cite web |url=https://www.sandoz.ca/en/news/media-releases/sandoz-canada-launches-sandoz-apremilast-0 |title= Sandoz Canada launches PrSandoz Apremilast |date=14 November 2022 |website= Sandoz Canada |access-date=18 August 2023 }} In April 2023, an American court case confirmed Amgen's patents on Otezla until 2028, delaying the introduction of generics until at least that date.{{cite web |url=https://www.reuters.com/legal/amgen-wins-appeal-us-patent-case-over-generic-psoriasis-drugs-2023-04-19/ |title= US Amgen ruling keeps generic psoriasis drug off market until 2028|last=Brittain |first=Brian |date=19 April 2023 |publisher=Reuters |access-date=18 August 2023 }} In February 2024, the Committee for Medicinal Products for Human Use of the European Medicines Agency adopted a positive opinion, recommending the granting of a marketing authorization for the medicinal product Apremilast Accord, intended for the treatment of psoriatic arthritis, psoriasis and Behcet's disease.{{cite web | title=Apremilast Accord EPAR | website=European Medicines Agency (EMA) | date=22 February 2024 | url=https://www.ema.europa.eu/en/medicines/human/EPAR/apremilast-accord | access-date=23 February 2024}} The applicant for this medicinal product is Accord Healthcare S.L.U. Apremilast Accord was approved for medical use in the European Union in April 2024.

Apremilast has been studied as a treatment for alcohol use disorder.{{cite journal | vauthors = Grigsby KB, Mangieri RA, Roberts AJ, Lopez MF, Firsick EJ, Townsley KG, Beneze A, Bess J, Eisenstein TK, Meissler JJ, Light JM, Miller J, Quello S, Shadan F, Skinner M, Aziz HC, Metten P, Morrisett RA, Crabbe JC, Roberto M, Becker HC, Mason BJ, Ozburn AR | title = Preclinical and clinical evidence for suppression of alcohol intake by apremilast | journal = The Journal of Clinical Investigation | volume = 133 | issue = 6 | date = March 2023 | pmid = 36656645 | pmc = 10014105 | doi = 10.1172/JCI159103 }}{{cite journal | vauthors = Blednov YA, Da Costa AJ, Tarbox T, Ponomareva O, Messing RO, Harris RA | title = Apremilast Alters Behavioral Responses to Ethanol in Mice: I. Reduced Consumption and Preference | journal = Alcoholism: Clinical and Experimental Research | volume = 42 | issue = 5 | pages = 926–938 | date = May 2018 | pmid = 29469962 | pmc = 5915912 | doi = 10.1111/acer.13616 }}

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