Diagnosis: Hidradenitis Suppurativa.
Treatment: Pharmacy/Prescription Drug (Otezla).

The health plan denied the requested prescription drug (Otezla). The health plan's determination is overturned.

This patient is a woman with a several year history of severe hidradenitis suppurativa. She has undergone multiple treatments including five surgeries (axilla, inguinal, buttocks), Adalimumab, Doxycycline, Prednisone, Spironolactone, Infliximab (with which she had anaphylaxis-type reaction), Metformin, and intralesional Kenalog. Per the most recent clinic note she had worsened lesions in the axillae and inguinal region while taking Humira 40 mg (milligrams) weekly, Doxycycline 200 mg nightly, Spironolactone, and Metformin extended release (XR) 500 mg daily. The patient has had partial improvement with her current treatments but continues to have significant symptoms, and thus the patient's dermatologist would like to add Apremilast.

The health plan's determination is overturned, in whole.

The proposed treatment of adding Apremilast is likely to be more beneficial than standard treatment for this patient. This patient has undergone multiple therapies that are on the more aggressive end of standard treatments for hidradenitis suppurativa, including multiple surgeries, Adalimumab, Infliximab, Metformin, Spironolactone, and oral antibiotics. At the current time, Apremilast would be best classified as an experimental therapy. However, there is evidence to suggest potential benefit. To date in the literature, there has been one randomized control study (n=20)[1], one uncontrolled open-label study (n=20)[2], one case series (n=9)[3], and two case reports (n=2)[4] examining the effect of Aprelimast in hidradenitis suppurativa. The overall conclusion of these studies and reports is that there was improvement in patients receiving Apremilast with moderate to severe hidradenitis. This benefit included patients who were resistant or not fully responsive to standard treatments including Adalimumab, as this patient has been noted to be. In the randomized controlled trial with n=20, more than half of patients (8 out of 15) who received Apremilast had significantly decreased abscess and nodule count and improved pain when compared to the control group [1].

I would recommend supporting at least a 4-6-month trial of Apremilast.