1
|
Gogulescu A, Blidisel A, Soica C, Mioc A, Voicu A, Jojic A, Voicu M, Banciu C. Neurological Side Effects of TNF-α Inhibitors Revisited: A Review of Case Reports. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1409. [PMID: 39336450 PMCID: PMC11433993 DOI: 10.3390/medicina60091409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 08/27/2024] [Accepted: 08/28/2024] [Indexed: 09/30/2024]
Abstract
Over the past two decades, the use of tumor necrosis factor alpha (TNF-α) inhibitors has significantly improved the treatment of patients with immune-mediated inflammatory diseases. Firstly, introduced for rheumatoid arthritis, these inhibitors are currently approved and used for a variety of conditions, including ankylosing spondylitis, Crohn's disease, juvenile idiopathic arthritis, psoriasis, psoriatic arthritis, ulcerative colitis, and chronic uveitis. Despite their immense therapeutic efficacy, TNF-α inhibitors have been associated with neurological adverse effects that bring new clinical challenges. The present review collects data from multiple studies to evaluate the incidence and the relationship between TNF-α inhibitors and neurological side effects and to explore the potential underlying mechanisms of this association. Moreover, it highlights the importance of patient selection, particularly in the case of individuals with a history of demyelinating diseases, raises awareness for clinicians, and calls for ongoing research that will improve TNF-α targeting strategies and offer safer and more effective therapeutic options.
Collapse
Affiliation(s)
- Armand Gogulescu
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Alexandru Blidisel
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Codruta Soica
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Alexandra Mioc
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Adrian Voicu
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Alina Jojic
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Mirela Voicu
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Christian Banciu
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| |
Collapse
|
2
|
Shastri A, Al Aiyan A, Kishore U, Farrugia ME. Immune-Mediated Neuropathies: Pathophysiology and Management. Int J Mol Sci 2023; 24:7288. [PMID: 37108447 PMCID: PMC10139406 DOI: 10.3390/ijms24087288] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.
Collapse
Affiliation(s)
- Abhishek Shastri
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Ahmad Al Aiyan
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Uday Kishore
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK
| |
Collapse
|
3
|
Romano C, Esposito S, Ferrara R, Cuomo G. Choosing the most appropriate biologic therapy for Crohn’s disease according to concomitant extra-intestinal manifestations, comorbidities, or physiologic conditions. Expert Opin Biol Ther 2019; 20:49-62. [DOI: 10.1080/14712598.2020.1689953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ciro Romano
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Sergio Esposito
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Roberta Ferrara
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Giovanna Cuomo
- Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| |
Collapse
|
4
|
Abstract
AbstractA majority of patients with Guillain-Barré syndrome (GBS) have tendency of a good recovery. Our aim was to evaluate the outcome of the disease 1 and 3 years after GBS symptom onset. Methods: During 2014, GBS was diagnosed in 82 patients in seven tertiary healthcare centers. Neurological follow-up was conducted in 57 (70%) patients after 1 year, and in 54 (66%) after 3 years. Functional disability was estimated according to the GBS disability scale (GDS), with a score of 0-3 indicating mild disability and a score of 4-6 indicating severe disability during acute phase, whereas a score >1 indicated poor recovery on follow-ups. Visual analog scale was used to assess sensory symptoms and musculoskelatal pain, and Krupp’s Fatigue Severity Scale was used to asses fatigue. Results: Poor functional outcome was found in 39% of GBS patients at year 1 and 30% at year 3. Paresthesias/dysesthesias were detected in 60% of patients after 1 year and 43% after 3 years. Musculoskeletal pain was present in 40% of patients at year 1 and 33% at year 3. Significant fatigue after 1 year was found in 21% of subjects and after 3 years in 7%. Parameters associated with poor functional outcome after 1 year were age >55 years (p=0.05), severe disability at admission (p<0.05), and on discharge (p<0.01). Poor functional outcome after 3 years was associated with male gender (p<0.05) and severe disability on discharge (p=0.06). Conclusion: One and even three years after GBS onset, a substantial number of patients had neurological sequelae, including functional disability, sensory symptoms, pain, and fatigue.
Collapse
|
5
|
Lee JH, Park JS, Park D. Successful IVIG treatment without discontinuation of TNF-α blocker in Guillain-Barre syndrome induced by adalimumab in patient with Crohn's disease. Neurol Sci 2017; 39:595-598. [PMID: 29101591 DOI: 10.1007/s10072-017-3179-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Jong-Hak Lee
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, South Korea
| | - Jin-Sung Park
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Donghwi Park
- Deparment of Pharmacology, School of Medicine, Kyungpook National University, Daegu, South Korea. .,Department of Rehabilitation Medicine, Daegu Fatima Hospital, Ayangro 99, Dong gu, Daegu, 41199, South Korea.
| |
Collapse
|
6
|
Patwala K, Crump N, De Cruz P. Guillain-Barré syndrome in association with antitumour necrosis factor therapy: a case of mistaken identity. BMJ Case Rep 2017; 2017:bcr-2017-219481. [PMID: 28679512 PMCID: PMC5534643 DOI: 10.1136/bcr-2017-219481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 11/04/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an immune-mediated disease characterised by evolving ascending limb weakness, sensory loss and areflexia. Two-thirds of GBS cases are associated with preceding infection. However, GBS has also been described in association with antitumour necrosis factor (TNF) therapies including infliximab and adalimumab for chronic inflammatory disorders such as rheumatoid arthritis, ankylosing spondylitis and inflammatory bowel disease. We present the case of a patient who developed GBS while undergoing treatment with adalimumab in combination with azathioprine for severe fistulising Crohn's disease, and review the literature on neurological adverse events that occur in association with anti-TNF therapy. We also propose an approach to the optimal management of patients who develop debilitating neurological sequelae in the setting of anti-TNF therapy.
Collapse
Affiliation(s)
- Kurvi Patwala
- Department of Gastroenterology, Austin Health, Heidelberg, Australia
| | - Nicholas Crump
- Department of Neurology, Austin Health, Heidelberg, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Heidelberg, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| |
Collapse
|
7
|
Cançado GGL, Vilela EG. Guillain-Barré syndrome during adalimumab therapy for Crohn´s disease: coincidence or consequence? Scand J Gastroenterol 2017; 52:473-476. [PMID: 27931132 DOI: 10.1080/00365521.2016.1263682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We report the case of a 64-year-old patient diagnosed with extensive ileal Crohn´s disease who developed Guillain-Barré syndrome after starting biological therapy with adalimumab. Neurologic involvement associated with inflammatory bowel diseases is recognized as an extra-intestinal manifestation. After the breakthrough of antitumor necrosis factor alpha (anti-TNF-α) agents, an increasing number of cases of acute inflammatory demyelinating polyneuropathies have been reported; however, only one case has been described in a patient with Crohn´s disease. Although a causal relationship between Guillain-Barré syndrome and TNF-α antagonist therapy cannot be proven, this report emphasizes the need to monitor for neurologic signs and symptoms in patients with inflammatory bowel diseases, with or without biological therapy, to avoid severe and irreversible complications associated with demyelinating diseases.
Collapse
Affiliation(s)
- Guilherme Grossi Lopes Cançado
- a Instituto Alfa de Gastroenterologia , Hospital das Clínicas da Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Eduardo Garcia Vilela
- a Instituto Alfa de Gastroenterologia , Hospital das Clínicas da Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| |
Collapse
|
8
|
Abstract
Patients with inflammatory bowel disease can present with a wide variety of symptoms. Most are related to disease activity and should be managed with appropriate medical therapy for inflammatory bowel disease. However, some patients may develop symptoms due to the side effects of the medications, or due to immunosuppression. In these cases, the offending medications should be discontinued until resolution of the symptoms and a few may be able to restart therapy. Symptoms can also occur as an extraintestinal manifestation of the disease or due to concomitant autoimmune-mediated disorders. Regardless of the etiology, symptoms should be addressed promptly with immediate evaluation and appropriate therapy, as a delay may lead to permanent sequela.
Collapse
Affiliation(s)
- Bincy P Abraham
- Houston Methodist Hospital, 6550 Fannin St., Smith Tower, Suite 1001 Houston, TX 77030 USA
| |
Collapse
|
9
|
Yanagida H, Sugimoto K, Izu A, Wada N, Sakata N, Takemura T. Guillain-Barré syndrome and Crohn disease: a case report. J Child Neurol 2014; 29:NP78-80. [PMID: 24092893 DOI: 10.1177/0883073813503903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Development of both Crohn disease and Guillain-Barré syndrome likely involves autoimmunity associated with excessive inflammatory cytokines. We treated a girl who developed Guillain-Barré syndrome during the course of Crohn disease. Although high-dose γ-globulin therapy administered initially for Guillain-Barré syndrome was ineffective, plasmapheresis ameliorated her acute neuropathic symptoms. Crohn disease was managed with Salazopyrin administration and enteral feeding. Chronic inflammation of the intestinal mucosa caused by Crohn disease can allow presentation of microbial intestinal antigens normally hidden from the immune system. Such presentation could incite an extraintestinal immune response on the basis of molecular mimicry, leading to activation of systemic autoimmunity against the nervous system. Accordingly, concurrence of Guillain-Barré syndrome and Crohn disease in our patient appeared to result from shared autoimmune mechanisms and systemic and local increases in cytokine concentrations. The patient also developed erythema nodosum and gall stones, relatively common complications of Crohn disease. However, Guillain-Barré syndrome is rare.
Collapse
Affiliation(s)
- Hidehiko Yanagida
- Department of Pediatrics, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Keisuke Sugimoto
- Department of Pediatrics, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Akane Izu
- Department of Pediatrics, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Norihisa Wada
- Department of Pediatrics, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Naoki Sakata
- Department of Pediatrics, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Tsukasa Takemura
- Department of Pediatrics, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| |
Collapse
|
10
|
Casella G, Tontini GE, Bassotti G, Pastorelli L, Villanacci V, Spina L, Baldini V, Vecchi M. Neurological disorders and inflammatory bowel diseases. World J Gastroenterol 2014; 20:8764-8782. [PMID: 25083051 PMCID: PMC4112885 DOI: 10.3748/wjg.v20.i27.8764] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/14/2014] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Extraintestinal manifestations occur in about one-third of patients living with inflammatory bowel disease (IBD) and may precede the onset of gastrointestinal symptoms by many years. Neurologic disorders associated with IBD are not frequent, being reported in 3% of patients, but they often represent an important cause of morbidity and a relevant diagnostic issue. In addition, the increasing use of immunosuppressant and biological therapies for IBD may also play a pivotal role in the development of neurological disorders of different type and pathogenesis. Hence, we provide a complete and profound review of the main features of neurological complications associated with IBD, with particular reference to those related to drugs and with a specific focus on their clinical presentation and possible pathophysiological mechanisms.
Collapse
|
11
|
Birnbaum J, Bingham CO. Non-length-dependent and length-dependent small-fiber neuropathies associated with tumor necrosis factor (TNF)-inhibitor therapy in patients with rheumatoid arthritis: expanding the spectrum of neurological disease associated with TNF-inhibitors. Semin Arthritis Rheum 2013; 43:638-47. [PMID: 24439654 DOI: 10.1016/j.semarthrit.2013.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/21/2013] [Accepted: 10/24/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Small-fiber neuropathy causes severe burning pain, requires diagnostic approaches such as skin biopsy, and encompasses two subtypes based on distribution of neuropathic pain. Such biopsy-proven subtypes of small-fiber neuropathies have not been previously described as complications of tumor necrosis factor (TNF)-inhibitor therapy. METHODS We therefore characterized clinical and skin biopsy findings in three rheumatoid arthritis (RA) patients who developed small-fiber neuropathies associated with TNF-inhibitors. We also conducted a systematic review of the literature to characterize subtypes of neuropathies previously reported in association with TNF-inhibitor therapy. RESULTS Two patients presented with a "non-length-dependent" small-fiber neuropathy, experiencing unorthodox patterns of burning pain affecting the face, torso, and proximal extremities. Abnormal skin biopsy findings were limited to the proximal thigh, which is a marker of proximal-most dorsal root ganglia degeneration. In contrast, one patient presented with a "length-dependent" small-fiber neuropathy, experiencing burning pain only in the feet. Abnormal skin biopsy findings were limited to the distal feet, which is a marker of distal-most axonal degeneration. One patient developed a small-fiber neuropathy in the context of TNF-inhibitor-induced lupus. In all patients, neuropathies occurred during TNF-inhibitor-induced remission of RA disease activity and improved on withdrawal of TNF-inhibitors. CONCLUSIONS We describe a spectrum of small-fiber neuropathies not previously reported in association with TNF-inhibitor therapy, with clinical and skin biopsy findings suggestive of dorsal root ganglia as well as axonal degeneration. The development of small-fiber neuropathies during inactive joint disease and improvement of neuropathic pain upon withdrawal of TNF-inhibitor suggest a causative role of TNF-inhibitors.
Collapse
Affiliation(s)
- Julius Birnbaum
- Division of Rheumatology, The Johns Hopkins University School of Medicine, 5200 Eastern Ave, Baltimore, MD 21224.
| | - Clifton O Bingham
- Department of Neurology, The Johns Hopkins University School of Medicine, 5200 Eastern Ave, Baltimore, MD 21224
| |
Collapse
|
12
|
Alvarez-Lario B, Prieto-Tejedo R, Colazo-Burlato M, Macarrón-Vicente J. Severe Guillain–Barré syndrome in a patient receiving anti-TNF therapy. Consequence or coincidence. A case-based review. Clin Rheumatol 2013; 32:1407-12. [DOI: 10.1007/s10067-013-2272-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
|
13
|
Abstract
Inflammatory bowel diseases, such as Crohn's disease, ulcerative colitis, autoantibody driven celiac disease and infectious Whipple's disease can all be associated with neurological symptoms. The neurological manifestation may occur even before the gastrointestinal symptoms or the enteropathic symptoms can even be absent as in celiac disease. These diseases can be caused by malresorption and lack of vitamins due to enteral inflammation as well as (auto-)immunological mechanisms and drug-associated side effects. Thus, inflammatory bowel diseases have to be considered in the differential diagnosis. In this review the most common neurological manifestations of these diseases will be described as well as the diagnostic approach.
Collapse
|
14
|
Vallat JM, Rabin M, Magy L. Peripheral neuropathies in rheumatic disease—a guide to diagnosis. Nat Rev Rheumatol 2012; 8:599-609. [DOI: 10.1038/nrrheum.2012.138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
15
|
Current world literature. Curr Opin Rheumatol 2012; 24:586-94. [PMID: 22871955 DOI: 10.1097/bor.0b013e32835793df] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|