Chronic sarcoid arthritis treated with intraarticular etanercept

Intra-articular injections of biological disease-modifying anti-rheumatic drugs in inflammatory arthropathies: An up-to-date narrative review

INTRODUCTION

Since the 1990s thebiological disease-modifying anti-rheumatic drugs (bDMARDs) have revolutionized the treatment of chronic dysimmune inflammatory arthropathies such as Rheumatoid Arthritis, Psoriatic Arthritis and Axial Spondylarthritis. Nevertheless, despite a full treatment regimen, mono- and oligoarticular persistence of the synovitis is sometimes observed. The intra-articular (IA) use of bDMARD drugs could resolve the persistent joint inflammation and result in a reduction in the degree of immunosuppression of individuals; moreover, the use of these drugs intra-articularly could be associated with a reduction in the treatment-related costs.

METHODS

We extensively searched via PubMed and Google Scholar articles using as keywords "etanercept", "infliximab", "adalimumab", "certolizumab", "golimumab", "tocilizumab", "ixekizumab", "secukinumab", "rituximab" each combined with "intra-articular injection".

RESULTS

We found and evaluated 161 papers, and then we selected 24 that were highly related to the topic of the present work. The articles examined a total of 349 patients, 85 males (M), and 168 females (F), mean age of 44.75±12.09 years old and considered 556 treated joints. Three hundred and forty-one patients were affected by Rheumatoid Arthritis, 198 by Psoriatic Arthritis, 56 by Axial Spondylarthritis, 26 by Juvenile Idiopathic Arthritis, 19 by Undifferentiated Arthritis, 1 by arthritis associated with inflammatory bowel disease and 9 patients by an unspecified inflammatory articular disorder. All patients were treated intra-articularly with a TNFα inhibitor among Adalimumab, Etanercept or Infliximab. Side effects were documented in 9 out of 349 (2.57%) treated patients and all were mild or moderate. In some cases the effectiveness of IA bDMARDs treatment was maintained for several months, however in the few published randomized controlled trials(RCTs) the corticosteroids (GCs) appeared to act better when administered intra-articularly compared to bDMARDs.

CONCLUSIONS

The IA use of bDMARDs seems to be weakly effective in the management of resistant synovitis and not superior to GCs injections. The treatment's main limit appears to be the poor persistence of the compound in the joint.

Sarcoidosis with musculoskeletal manifestations: systematic review of non-pharmacological and pharmacological treatments

We aimed to summarise effects and use of non-pharmacological and pharmacological treatments for sarcoidosis with musculoskeletal manifestations. We systematically searched the Cochrane Library, Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, clinical.trials.gov, PROSPERO and PEDro for systematic reviews from 2014 to 2022 and for primary studies from date of inception to March 29, 2022, and studies with patients diagnosed with sarcoidosis with musculoskeletal manifestations. Inclusion criteria required that studies reported effects of non-pharmacological and/or pharmacological treatments or number of patients receiving these treatments. Results were reported narratively and in forest plots. Eleven studies were included. No systematic reviews fulfilled our inclusion criteria. None of the included studies had a control group. We found that between 23 and 100% received corticosteroids, 0-100% received NSAIDs, 5-100% received hydroxychloroquine, 12-100% received methotrexate, 0-100% received TNF inhibitors, and 3-4% received azathioprine. Only ten patients in one study had used non-pharmacological treatments, including occupational therapy, chiropractic and acupuncture. There are no controlled studies on treatment effects for patients with sarcoidosis with musculoskeletal manifestations. We found 11 studies reporting use of pharmacological treatments and only one study reporting use of non-pharmacological treatments. Our study identified major research gaps for pharmacological and non-pharmacological treatment in musculoskeletal sarcoidosis and warrant randomised clinical trials for both.

Musculoskeletal Manifestations of Sarcoidosis

Since its initial description in the late 19th century, sarcoidosis has been extensively studied. Although the general mechanism of immune activation is known, many details especially in the context of disease associations are still missing. One of such associations is the musculoskeletal complications that are widely variable in terms of presentation and response to treatment. Sarcoidosis can involve the joints leading to acute and, less commonly chronic, arthritis. While acute arthritis is mostly self-resolving in nature, chronic arthritis may lead to deformity and destruction of the joint. Sarcoidosis can also involve the muscles, leading to different pathologies primarily categorized according to the clinical presentation, despite the efforts to find a new classification based on imaging, histological, and clinical findings. The bones can be directly and indirectly affected. Different types of bone lesions have been described, although around half of these patients remain asymptomatic. Osteoporosis, increased risk of fractures, hypercalcemia, and hypercalciuria are examples of the indirect effect of sarcoidosis on the bones, possibly contributed to elevated levels of calcitriol. Nevertheless, sarcoidosis can be associated with small-vessel, medium-vessel, and large vessel vasculitis, although it is frequently difficult to differentiate between the co-existence of a pure vasculitis and sarcoidosis and sarcoid vasculitis.

TNF inhibitor treating osseous sarcoidosis and dactylitis: case and literature review

A 49-year-old African American male with multiorgan sarcoidosis presented with recurrent episodes of dactylitis and arthritis. Imaging had shown sarcoid osseous involvement of both hands. This would improve temporarily with high-dose corticosteroids but once tapered, he would experience recurrent flares. Despite several different oral immunosuppressant regimens, significant improvement was only observed after the initiation of adalimumab. Not only was adalimumab successful in symptomatic relief, in addition, patient continues to be in remission with no recurrent episodes of dactylitis. Prednisone was successfully tapered from 40 to 3 mg daily. This improvement with TNF inhibitors has been reported with other manifestations of sarcoidosis including pulmonary and ocular involvements. Osseous sarcoidosis is a very rare presentation, and little information regarding treatment with TNF inhibitors is available. TNF inhibitors should be considered as the next-step therapy in resistant cases of osseous sarcoidosis and dactylitis not responding to corticosteroids and traditional immunosuppressant therapy.

Musculoskeletal Manifestations of Sarcoidosis: A Review Article

BACKGROUND

Sarcoidosis is a multisystem inflammatory disease with an etiology that is not clearly understood. Amongst the different organs that may be affected, the lungs are the most common. Musculoskeletal manifestations of the disease are uncommon.

OBJECTIVES

They include arthropathy, bone lesions, or myopathy, all of which may occur as initial symptoms or develop during the course of the disease.

METHODS

Articular involvement my present as arthralgia or arthritis. Skeletal complications usually develop in the chronic state of the disease. Muscular disease is rare and usually asymptomatic. Appropriate imaging modalities including X-ray, MRI, FDG-PET/CT assist in the diagnosis of rheumatic sarcoidosis. However, biopsy is necessary for definite diagnosis.

RESULT AND CONCLUSION

In most cases of musculoskeletal involvement, NSAIDs and corticosteroids are sufficient for symptomatic management. For more resistant cases immunosuppressive drugs (i.e., methotrexate) and TNF- inhibitors are used. Our aim is to review various types of musculoskeletal involvement in sarcoidosis and their existing treatment options.

Safety and efficacy of intra-articular infliximab therapy for treatment-resistant temporomandibular joint arthritis in children: a retrospective study

OBJECTIVE

TM joint (TMJ) arthritis occurs in up to 80% of children with JIA and can result in substantial deformity. TMJ arthritis can be refractory to systemic immunosuppressive therapy and IA CS injections (IACIs). Multiple studies have shown the benefit of IA infliximab injections (IAIIs) in several different joints, so we used intra-articular infliximab injections (IAIIs) in JIA patients with TMJ arthritis refractory to IACIs. The objective of the study was to test the safety and efficacy of IAII therapy for TMJ arthritis.

METHODS

Retrospective chart review was performed for all children with JIA treated at a single centre who received one or more IAIIs. Outcomes assessed were safety of the injections as well as efficacy as evidenced by maximal incisal opening (MIO) and MRI findings.

RESULTS

Twenty-four children underwent bilateral IAIIs, all of whom had at least one follow-up visit after the final injection. All 24 tolerated the injections without any adverse events. MIOs were unchanged in patients before and after IAII. Findings of acute synovitis were present in 30/46 (65%) TMJs at baseline, 44/48 (92%) following completion of the IACI and 42/48 (88%) following completion of the IAII; findings of chronic synovitis at the three time points were 12/46 (26%), 29/48 (60%) and 38/48 (79%). Resolution of the arthritis was observed in six TMJs.

CONCLUSION

IAII was safe and it reversed the progression of TMJ arthritis in some patients with refractory disease. Future studies will evaluate the efficacy of infliximab vs CS injections as initial therapy for TMJ arthritis.

Tumor necrosis factor-alpha inhibitor treatment for sarcoidosis

Sarcoidosis is a chronic multisystem disease of unknown etiology, characterized by noncaseating granulomatous infiltration of virtually any organ system. Treatment is often undertaken in an attempt to resolve symptoms or prevent progression to organ failure. Previous studies have suggested a prominent role for tumor necrosis factor-alpha (TNF-α) in the inflammatory process seen in sarcoidosis. TNF-α and interleukin-1 are released by alveolar macrophages in patients with active lung disease. Corticosteroids have proved to be efficacious in the treatment of sarcoidosis, possibly by suppressing the production of TNF-α and other cytokines. Three agents are currently available as specific TNF antagonists: etanercept, infliximab, and adalimumab. Although data from noncomparative trials suggest that all three have comparable therapeutic effects in rheumatoid arthritis, their effects in a granulomatous disease such as sarcoidosis are less consistent. In this review, current data on the effectiveness are summarized.

Cytokine modulators in the treatment of sarcoidosis

Sarcoidosis is a granulomatous lung disease in which several cytokines play a pivotal pathogenetic role. Steroid-resistant disease can be treated with immunosuppressive drugs, antimalarial therapies and recently with anti-TNFα agents. The use of biological agents for the treatment of sarcoidosis springs from research into the pathogenesis of the disease and also from the experience of rheumatologists with other chronic inflammatory diseases. Rituximab, golimumab and ustekinumab are cytokine modulators, useful in the treatment of immunoinflammatory disorders, for which randomized trials to evaluate safety and efficacy in sarcoidosis are not yet available. Novel anticytokine drugs administered alone or in association may offer a new approach to treatment of the disease. This review focuses on recent advances in anti-TNFα agents and cytokine modulators for the treatment of sarcoidosis and their therapeutic prospects.

Sarcoidosis during infliximab therapy for Crohn's disease

Tumor necrosis factor-alpha (TNF-alpha) antagonists are effective for inflammatory diseases, such as Crohn's disease, rheumatoid arthritis (RA) and psoriasis. Although TNF-alpha antagonists are also useful for sarcoidosis, paradoxical occurrence of sarcoidosis or sarcoidal reaction may be observed. We report a Crohn's disease patient, who developed sarcoidosis during infliximab therapy. A 35-year-old man had been receiving infliximab for 7 months for Crohn's disease. He developed cough and fever, accompanied by an infiltrated erythematous plaque on his right knee. The chest radiography, skin biopsy and laboratory findings were all consistent with sarcoidosis.

[TNFα blocking agents and sarcoidosis: an update]

Increased production of TNFα by alveolar macrophages and involvement of TNFα in granuloma formation suggest that this cytokine is involved in the pathophysiology of sarcoidosis. The three available TNFα blocking agents have been tested in sarcoidosis refractory to corticosteroids or immunosuppressive drugs. Data are available from isolated case reports or limited series of patients treated in open label trials with favourable issue with anti-TNFα monoclonal antibodies. Two randomized placebo controlled studies evaluated the efficacy of infliximab in pulmonary and extra-pulmonary sarcoidosis, showing that infliximab improves significantly extra-pulmonary disease. There is no significant difference between infliximab and placebo in the treatment of pulmonary manifestations. Etanercept showed no efficacy for treating ocular sarcoidosis in a controlled trial and for pulmonary disease in an open label trial. Paradoxical cases of proven sarcoidosis have been reported in patients receiving anti-TNFα agents for chronic inflammatory rheumatic diseases. A literature review identified 28 cases, including 16 with etanercept, eight with infliximab and four with adalimumab. Although these cases were mainly reported with etanercept, paradoxical sarcoidosis has been reported with the three available anti-TNFα agents, suggesting a class effect. Changes in the cytokine balance may be involved in these cases of induced sarcoidosis, which must be known by the clinician.

Efficacy and safety of combining intra-articular methylprednisolone and anti-TNF agent to achieve prolonged remission in patients with recurrent inflammatory monoarthritis

OBJECTIVE

To control local inflammation, the role of intra-articular corticosteroid is well established; similarly, with time there are more reports on the experience of intra-articular anti-TNF agent for localized joint inflammation. The aim of this study was to assess the safety, local tolerability and clinical response after combining intra-articular administration of corticosteroids and anti-TNF agents for recurrent inflammatory monoarthritis.

METHODS

Patients with recurrent monoarthritis of the knee were recruited from our inflammatory arthritis clinics. These patients required intra-articular corticosteroids every 8-12 weeks, with good short-term results. Five such consecutive patients were invited to partake in this study. Patients were maintained on their baseline immunosuppressive therapy. After aspiration of knee joint, the involved joint was injected with 80mg of methylprednisolone mixed with 5ml of lignocaine 1%; this was followed by the injection of an anti-TNF agent.

RESULTS

In majority of our patients (three out of five), combining anti-TNF agent and methylprednisolone led to prolonged anti-inflammatory response, and these patients remain in remission to date (mean follow-up of 12 months). These responders were noted to be naive to anti-TNF therapy. Conversely, the remaining two patients were found to be on baseline systemic anti-TNF therapy, and both of them failed to respond either partly or completely.

CONCLUSION

Combining intra-articular corticosteroid and anti-TNF agent has proved to be safe in our cohort of patients. We conclude that in particular subset of patients who suffer from recurrent inflammatory monoarthritis or oligoarthritis, combination therapy of intra-articular corticosteroids and anti-TNF agents appears attractive and promising.

Intra-Articular Injections of Infliximab in the Treatment of Inflammatory Rheumatic Diseases: Case Reports and Review of Literature

Inflammatory chronic diseases involving joints together with other organs are usually treated with a systemic approach. In a few cases, where arthritis is not responsive to traditional treatments, an intraarticular (I.A.) therapy could be useful. Furthermore, patients not eligible for systemic therapy with anti-TNF or other DMARDs, as well as patients with an initial arthritis with the involvement of a single joint, such as the knee or hip joint, could use the I.A. injection therapy. In this article we report our experience with five patients affected by rheumatic inflammatory diseases, not responding to traditional systemic DMARDs-based therapies or not eligible for systemic use of biological response modifiers who underwent ultrasound-guided I.A. injection of Infliximab. Three of 5 patients showed a positive and long-lasting response to treatment with local Infliximab. Safety profile was good according to literature data. Moreover, in this article we review the literature on this therapeutic approach. This is the first report of I.A. use of Infliximab in the hip joint.

Antinociceptive effects of tumor necrosis factor alpha neutralization in a rat model of antigen-induced arthritis: evidence of a neuronal target

OBJECTIVE

The reduction of pain in the course of antiinflammatory therapy can result from an attenuation of the inflammatory process and/or from the neutralization of endogenous mediators of inflammation that act directly on nociceptive neurons. The purpose of this study was to investigate whether analgesic effects of the neutralization of tumor necrosis factor alpha (TNFalpha) are due to an attenuation of inflammation or whether direct neuronal effects significantly contribute to pain relief in the course of therapy.

METHODS

Locomotor and pain-related behavior and histology were assessed in rats with chronic antigen-induced arthritis (AIA) in the knee joint, and the rats were treated with systemic saline, etanercept, or infliximab. The expression of TNF receptors (TNFRs) in dorsal root ganglia was measured using immunohistochemical analysis and polymerase chain reaction. Action potentials were recorded from afferent Adelta fibers and C fibers of the medial knee joint nerve, and etanercept and infliximab were injected intraarticularly into normal or inflamed knee joints (AIA or kaolin/carrageenan-induced inflammation).

RESULTS

In rats with AIA, both etanercept and infliximab significantly decreased inflammation-induced locomotor and pain-related behavior, while joint swelling was only weakly attenuated and histomorphology still revealed pronounced inflammation. A large proportion of dorsal root ganglion neurons showed TNFRI- and TNFRII-like immunoreactivity. Intraarticular injection of etanercept reduced the responses of joint afferents to mechanical stimulation of the inflamed joint starting 30 minutes after injection, but had no effect on responses to mechanical stimulation of the uninflamed joint.

CONCLUSION

Overall, these data show the pronounced antinociceptive effects of TNFalpha neutralization, thus suggesting that reduction of the effects of TNFalpha on pain fibers themselves significantly contributes to pain relief.

Development of sarcoidosis during etanercept therapy

This report describes a 65-year-old woman who developed granulomatous lesions consistent with sarcoidosis during etanercept therapy for rheumatoid arthritis. Hilar and mediastinal lymphadenopathy and multiple nodules in both lung fields developed 21 months after administration of etanercept. Noncaseating epithelioid cell granulomas consistent with sarcoidosis were detected in a lung biopsy specimen and in the parietal pleura obtained via thoracotomy. Diseases showing similar histologic changes were excluded, and a diagnosis of sarcoidosis was made. Etanercept was discontinued, which resulted in symptomatic relief, improvement of oxygenation and radiologic findings. There is substantial evidence of tumor necrosis factor-alpha involvement in the induction and maintenance of granuloma formation; however, we should keep in mind that granulomatous disease, such as sarcoidosis, can develop during treatment with a tumor necrosis factor-alpha blocking agent, such as etanercept.

Pulmonary Sarcoidosis Associated with Etanercept Therapy

We present a case of probable pulmonary sarcoidosis associated with the use of etanercept for psoriatic arthritis. Other cases of etanercept-induced granulomas and skin sarcoidosis were recently published in the medical literature, but we found only one case that involved lung sarcoidosis during etanercept therapy. We describe a 40-year-old man who was receiving etanercept for severe psoriatic arthritis and was admitted to the hospital with dyspnea and subfebrile illness several months after the start of treatment. His diagnosis was consistent exclusively with sarcoidosis. The patient's symptoms improved when etanercept was discontinued, but they did not resolve completely. Treatment with prednisone 40 mg led to complete improvement of his pulmonary disease. Etanercept therapy can induce or exacerbate sarcoidosis. The disease disappears when etanercept is discontinued, although treatment with corticosteroids is sometimes required, as in our patient. Use of the Naranjo adverse drug reaction probability scale revealed a probable likelihood (score of 6) that the adverse reaction was related to etanercept. The association of etanercept with sarcoidosis is still a rare finding. This case highlights the importance of monitoring and possibly discontinuing the drug when sarcoidosis is suspected. Patients should be monitored during and after etanercept therapy for manifestations suggesting sarcoidosis, and we recommend patients receive baseline chest radiography at the start of therapy with follow-up of respiratory symptoms.

Sarcoidosis, role of tumor necrosis factor inhibitors and other biologic agents, past, present, and future concepts

Tumor necrosis factor is a potent cytokine involved in the inflammatory process of many diseases. Agents that block tumor necrosis factor have been used in the treatment of various immune-mediated diseases, including rheumatoid arthritis, Crohn disease, psoriatic arthritis, and ankylosing spondylitis. Sarcoidosis is an immune-mediated inflammatory disorder of unknown etiology characterized by the formation of noncaseating granulomas. Tumor necrosis factor plays a major role in the inflammatory process seen in sarcoidosis. Sarcoidosis therapies with activity against tumor necrosis factor and specific anti-tumor necrosis factor therapies have been used with variable success. The long-term safety and efficacy of such therapies are yet to be determined in well-designed clinical trials with long-term follow-up.

Current and emerging strategies for the management of sarcoidosis

Sarcoidosis is a systemic inflammatory disorder of unknown etiology. Although any organ may be involved, the lungs are most frequently affected. The clinical course of the disease is highly variable, with up to two-thirds of untreated patients experiencing spontaneous remission within 12-24 months of onset of symptoms. When therapy is required, corticosteroids are considered standard, but studies demonstrating their ability to modify the long-term outcome in this disease are lacking. Often, the myriad of adverse side effects of corticosteroids necessitate the addition of immunosuppressants, cytotoxic agents or biologic therapies to maintain disease remission. Unfortunately, optimal therapeutic regimens have not been described. Patients who do not respond to therapy often experience progressive fibrotic changes and end-organ damage, which ultimately may result in significant morbidity or death. Agents commonly used to treat patients with sarcoidosis and emerging therapeutic options are discussed.