Réactions cutanées paradoxales sous traitement par tocilizumab

Tocilizumab-induced psoriatic eruption : a case report and a case-based review

BACKGROUND

Cases of psoriasis associated with Tocilizumab (TCZ) are scarce.

OBJECTIVE

To describe a new case of TCZ-associated psoriasis and to perform a case-based review of similar cases.

METHODS

We searched Medline/Pubmed, Embase, Scopus, Web of Science, and Directory of Open Access Journals databases using the terms « Tocilizumab » and « Psoriasis » in the French and English literature.

RESULTS

We report a 70-year-old woman with a history of Rheumatoid Arthritis who developed Infliximab-induced plaque psoriatic eruption of the soles and palms, that resolved after Infliximab interruption, then relapsed after TCZ relay, and eventually resolved after TCZ interruption. Including our case, we identified 16 cases of TCZ-induced psoriatic eruption. Three (21%) out of 14 patients had a history of cutaneous psoriasis - data were not available for 2 patients. Eight (50%) patients had previously received TNFα antagonists. TCZ was stopped for 10 patients and continued for 4 patients. For the 2 remaining patients, the interval between two injections of TCZ was shortened. All the patients with available follow-up data had an improvement of the eruption within 4 weeks.

CONCLUSION

To conclude, in case of TCZ-induced psoriatic eruption and in light of the published cases, we suggest using topical steroids and reassessing the patient 4 weeks later. If no healing is obtained, we suggest stopping TCZ, and treating the underlying disease with another drug. When no other drug is available, while waiting for more data regarding the value of IL-6 levels, it can be discussed to increase TCZ regimen, as it has been successful for 2 authors. Efficacy assessment of the chosen attitude should not take place before 4 weeks.

Tocilizumab-Induced Dermatosis in a Patient With Rheumatoid Arthritis

Rheumatoid arthritis is a chronic systemic autoimmune disease that results in symmetrical inflammatory polyarthritis with extra-articular involvement, including skin manifestations. It targets the lining of the synovial membranes and is treated with disease-modifying antirheumatic drugs. If left untreated, it leads to increased morbidity, mortality, and socioeconomic burdens. Tocilizumab is a humanized monoclonal antibody that binds to interleukin-6 receptors and is used to treat rheumatoid arthritis in patients with inadequate response to conventional synthetic therapy. This medication can cause adverse dermatologic events, such as urticaria, pruritus, and mild maculopapular rash. In this case, we report a 39-year-old woman with rheumatoid arthritis who developed tocilizumab-induced dermatosis.

Psoriasis induced by biological therapy

OBJECTIVE

To describe a multicentre case series of new onset or worsening of psoriasis in patients treated with biological drugs.

MATERIAL AND METHODS

Descriptive study. We reviewed the clinical history of patients with chronic inflammatory disease (CID) treated with biological drugs, who developed new onset or worsening of psoriasis during the follow-up period.

RESULTS

Twenty-six cases of paradoxical psoriasis (PP) were recorded. Ninety-three percent of the patients were treated with anti-TNFα and adalimumab was responsible for 50% of the cases. Only 5 patients had a personal history of psoriasis. The biological drug was discontinued in 13 patients. Lesion recurrence was more frequent when another anti-TNFα was reintroduced.

CONCLUSIONS

The PP is a reversible adverse effect that can be observed in patients exposed to biological drugs, mainly anti-TNFα.

Tocilizumab and its usage for skin diseases

The monoclonal anti-IL6 receptor antibody called Tocilizumab is widely used by rheumatologists for joint diseases. Its application in dermatology has mainly concerned scleroderma and Systemic Sclerosis in the last years. The most varied skin diseases treated with tocilizumab, such as psoriasis, psoriatic arthritis, Behcet's Syndrome, Lupus, and the already mentioned scleroderma up to multi-organ syndromes with skin involvement will be discussed. At the same time, there have been several side reactions to the drug involving the skin forcing careful skin monitoring during treatment. Despite the evidence currently available in the appropriate literature, there is no formal recommendation for any of these diseases to use Tocilizumab for therapeutic purposes. The aim of this review was to collect all the main evidence on the use and involvement of the drug in dermatological practice in order to stimulate further research or hypothesize on possible therapeutic options.

Psoriasis Induced by Biological Therapy

OBJECTIVE

To describe a multicentre case series of new onset or worsening of psoriasis in patients treated with biological drugs.

MATERIAL AND METHODS

Descriptive study. We reviewed the clinical history of patients with chronic inflammatory disease (CID) treated with biological drugs, who developed new onset or worsening of psoriasis during the follow-up period.

RESULTS

Twenty-six cases of paradoxical psoriasis (PP) were recorded. Ninety-three percent of the patients were treated with anti-TNFα and adalimumab was responsible for 50% of the cases. Only 5 patients had a personal history of psoriasis. The biological drug was discontinued in 13 patients. Lesion recurrence was more frequent when another anti-TNFα was reintroduced.

CONCLUSIONS

The PP is a reversible adverse effect that can be observed in patients exposed to biological drugs, mainly anti-TNFα.

Incidence of paradoxical reactions in patients treated with tocilizumab for rheumatoid arthritis: Data from the French registry REGATE

OBJECTIVES

Assess the frequency of paradoxical reactions encountered in daily practice under tocilizumab, using the REGATE (Registry-RoActemra) registry. The secondary objectives were to determine the type of paradoxical reaction and the consequences of these reactions.

METHODS

The REGATE registry is an independent prospective registry, promoted by the French Society of Rheumatology, consisting of patients treated with tocilizumab for rheumatoid arthritis. The paradoxical reaction was retained if it was a paradoxical precipitation of a condition for which tocilizumab was indicated, if tocilizumab was being used for an alternative indication, and if it appeared after at least one tocilizumab infusion.

RESULTS

Among the 1491 patients included with at least one follow-up visit (3429 patient-years), a paradoxical reaction occurred in 9 patients (0.60% of patients; 2.62/1000 patient-years). These were 7 de novo pathologies (3 vasculitis, 3 uveitis, 1 lupus) and 2 exacerbations of pre-existing conditions (1 vasculitis, 1 lupus). Permanent discontinuation of tocilizumab was chosen for 5 patients.

CONCLUSIONS

In the REGATE registry, the occurrence of paradoxical reactions in patients treated with tocilizumab was rare.

[Psoriatic arthritis during rituximab treatment of granulomatosis with polyangiitis: a new paradoxical side effect?]

INTRODUCTION

Rituximab is a monoclonal antibody targeting the CD20 molecule of the B lymphocyte. Its efficacy has been recently reported in ANCA-associated vasculitis. We report a case of psoriatic arthritis that occurs during a treatment with rituximab in granulomatosis with polyangiitis.

CASE REPORT

A 66-year-old woman, without past history of psoriasis, presented with a relapsing granulomatosis with polyangiitis in July 2010 with sinus and lung involvement. Treatment with rituximab was started, allowing a complete remission in 6 months. Two months after the first two infusions of rituximab she developed asymmetric arthritis of 3 distal interphalangeal joints. A few months later, the clinical presentation showed asymmetrical arthritis of the hands and wrists and dactylitis. Standard radiographs and MRI showed an inflammatory impairment according with psoriatic arthritis.

CONCLUSION

Accountability of rituximab was retained in the development of the disease given the chronology of psoriatic arthritis development. It may be a paradoxical reaction, by analogy to those observed in anti-TNFα.