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Old 12-07-2011
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Drug Alefacept weekly monitoring

A 26-year-old woman with widespread psoriasis comes to the office for a followup visit. She is concerned that the topical medications prescribed 1 month earlier are not working. She has dealt with the disease since she was 18 years of age and is quite frustrated with the efficacy of available treatments. Over the years she has been on methotrexate, ultraviolet light therapy, and cyclosporine, with variable results. During the visit she inquires if any new treatment alternatives have become available. Otherwise she is in good health and has no complaints. Her current medications include topical clobetasol dipropionate and topical calcipotriol. The family history is unremarkable. On physical examination, she is in no acute distress and her vital signs are within normal limits. A recent complete blood count, liver function test, and fasting lipid profile were all within the normal range. Inspection of the skin reveals generalized discrete and confluent erythematous plaques with silvery scale involving greater than 30% body surface area. There is prominent nail pitting and onycholysis. You tell her that there is a new class of biologic drugs that have become available recently for the treatment of moderate to severe psoriasis. You prescribe alefacept and explain that she will need to have weekly blood tests to monitor which of the following?

A. CD4+ T cell count
B. Complete blood count
C. Fasting lipids
D. Liver function tests
E. Platelet count
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Old 12-07-2011
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Should be CD4+ T cell count
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Old 12-07-2011
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is it CD4 cells...
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Old 12-07-2011
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A. CD4+ T cell count
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Old 12-07-2011
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A. CD4+ T cell count
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Old 12-08-2011
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A. CD4+ T cell count
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Old 12-08-2011
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The correct answer is A. An increased understanding of the immunologic basis of psoriasis, combined with major advances in various scientific disciplines, is enabling the development of new biologic therapies that selectively target the underlying cause of the disease. Biologic therapies are drugs that target the activity of T lymphocytes and cytokines responsible for the inflammatory nature of psoriasis. Alefacept is a dimeric fusion protein that binds to CD2 on memory-effector T cells, resulting in the inhibition of T cell activation and a reduced number of memory-effector T lymphocytes. Because it invariably causes apoptosis of T cells, a weekly CD4+ T cell count is mandatory to ensure patient safety. If the CD4+ count is 250 cells/mL or less, a dose of alefacept is deferred. If a week later the count remains at 250 cells/mL or less, the drug is discontinued altogether.
A complete blood count (choice B) is required at baseline and then initially weekly for monitoring of patients on methotrexate. Anemia and thrombocytopenia may develop soon after the drug is initiated and may require lowering the dose or complete discontinuation of the medication.
Fasting lipids (choice C) are mandatory at baseline and then on a monthly basis in all patients treated with systemic retinoids (acitretin or isotretinoin). Reversible elevation of the triglycerides may occur and treatment with lipid-lowering agents or discontinuation of the medication may be required.
Liver function tests (choice D) are performed on a monthly basis in patients with psoriasis treated with methotrexate and retinoids, as they may develop elevated transaminases. These changes are usually reversible on discontinuation of the medication.
A platelet count (choice E) is mandatory at baseline and then weekly for patients with psoriasis on methotrexate until the dose is stable. Subsequently, monitoring frequency can be reduced to biweekly or monthly for as long as the patient is on the same dose.
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