Psoriasis in patients taking TNF inhibitors: a new adverse reaction?

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Psoriasis in patients taking TNF inhibitors: a new adverse reaction?

June 15, 2004 Zosia Chustecka

Rheumawire

Berlin, Germany - A new potential adverse reaction to TNF-inhibitor

therapy was reported at the EULAR 2004 meeting last weekthe new onset of

psoriatic lesions or aggravation of existing lesions in patients using

these drugs. One report involves 8 patients with rheumatoid arthritis

(RA) and all 3 marketed products (etanercept [Enbrel®, Amgen/Wyeth],

infliximab [Remicade®, Centocor], and adalimumab [Humira®, Abbott

Laboratories]); the other involves 4 patients with ankylosing

spondylitis and 2 of the marketed products (etanercept and infliximab).

The finding is surprising and also counterintuitive, say the

researchers, as the TNF inhibitors have been shown in controlled

clinical trials to benefit psoriasis. In fact, etanercept has been

recently approved for marketing for this indication, and the other

products are also pursuing this therapeutic niche.

Both reports come from investigators at the Charite University of

Medicine in Berlin and were presented in posters that attracted a lot of

attention. One of the presenters, Dr Kary, told rheumawire that

several clinicians had told her that they, too, have seen this

phenomenon of psoriasis in their patients on TNF-inhibitor therapy. But

nobody appears to have reported it previously; in her search of the

literature, she found only 1 mention of skin lesions occurring in 1

patient participating in a clinical trial (with infliximab). [1]

Kary and colleagues reported details on 8 RA patients, all of whom

responded well to TNF-inhibitor treatment for their rheumatoid

arthritis. Of these patients, 3 were using the biologic as monotherapy,

3 were using it in combination with methotrexate, 1 in combination with

leflunomide, and 1 in combination with both methotrexate and

leflunomide.

Five patients developed psoriasis vulgaris, 4 of them with new-onset

psoriasis. Three patients developed psoriasis pustulosa; 2 of these pati

ents had a history of psoriasis but had nearly asymptomatic psoriasis

pustulosa before starting biologic treatment, Kary commented. Palmar

and/or plantar lesions occurred in half of the patients.

One patient in particular developed very severe psoriasis on her heel

after treatment with adalimumab, and this also recurred and remained

when she switched to etanercept and then infliximab, Kary told

rheumawire. The psoriasis became so severe that she stopped using

biologics altogether for 9 months, but the problem persisted

nevertheless. " The skin is still bad, but this patient is now on

low-dose etanercept and is managing as best she can with topical

treatments for the psoriasis, " Kary said.

" The reason for this adverse reaction of new-onset or aggravation of

psoriasis under TNF inhibition remains unclear, " the researchers

comment. " Hypothetically, in these RA patients, the inhibition of

THF-alpha influenced the manifestation of psoriatic skin lesions, which

is in contrast to the documented therapeutic benefit of TNF-alpha

antagonists, " they add.

Dr H Haibel and colleagues, also from the Charite Medical University in

Berlin, reported on 4 patients with ankylosing spondylitis (AS). Two

patients receiving infliximab both developed new manifestations of

psoriasis. In 1 patient, the psoriasis appeared after the 6-week

infusion and occurred mainly on the palms and plantar sole but also some

on the trunk; infliximab was stopped, and systemic glucocorticoids

begun, after which the skin lesions partially improved. In the other

patient, plantar and palmar psoriasis appeared after 10 months, but

infliximab therapy is continuing and the skin lesions are being treated

with topical medications and have shown no exacerbation. [2]

The other 2 AS patients were taking etanercept, and both had a history

of psoriasis. Etanercept therapy led to an exacerbation of plantar and

palmar psoriasis, after 4 and 7 months respectively, but in both cases

the lesions have been controlled with topical treatments; one patient is

continuing with etanercept, but the other stopped.

Haibel at al comment that this adverse effect is likely to be a class

effect. " Our preliminary data suggest that TNF-inhibitor therapy doesn't

have to be stopped necessarily in all patients when manifestation

occurs, " they add.

Sources

Kary S, Worm M, Fritz J, et al. New onset or

aggravation of psoriatic skin lesions in patients with definite

rheumatoid arthritis under treatment with TNF-alpha antagonists--report

of 8 cases. Presented at: EULAR 2004; Berlin, Germany; June 9-12, 2004.

Abstract FRI0095.

Haibel H, Spiller I, Strasser C. Unexpected new onset

or exacerbation of psoriasis in treatment of active ankylosing

spondylitis with TNF-alpha blocking agents: four case reports. Presented

at: EULAR 2004; Berlin, Germany; June 9-12, 2004. Abstract SAT0061.

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Mayo Clinic in Rochester

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