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Lahaye C, Tatar Z, Dubost JJ, Tournadre A, Soubrier M. Management of inflammatory rheumatic conditions in the elderly. Rheumatology (Oxford) 2020; 58:748-764. [PMID: 29982766 PMCID: PMC6477520 DOI: 10.1093/rheumatology/key165] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 05/08/2018] [Indexed: 12/21/2022] Open
Abstract
The number of elderly people with chronic inflammatory rheumatic diseases is increasing. This heterogeneous and comorbid population is at particular risk of cardiovascular, neoplastic, infectious and iatrogenic complications. The development of biotherapies has paved the way for innovative therapeutic strategies, which are associated with toxicities. In this review, we have focused on the scientific and therapeutic changes impacting the management of elderly patients affected by RA, SpA or PsA. A multidimensional health assessment resulting in an integrated therapeutic strategy was identified as a major research direction for improving the management of elderly patients.
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Affiliation(s)
- Clément Lahaye
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Zuzana Tatar
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Jean-Jacques Dubost
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Anne Tournadre
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Martin Soubrier
- CHU Clermont-Ferrand, Department of Rheumatology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
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Active Tuberculosis in Patients with Psoriasis Receiving Biologic Therapy: A Systematic Review. Am J Clin Dermatol 2019; 20:483-491. [PMID: 30919314 DOI: 10.1007/s40257-019-00432-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Biologic therapies pose a risk for opportunistic infections, especially for reactivating latent tuberculosis infection (LTBI). OBJECTIVE The aim was to describe the clinical features and mortality rate of active Mycobacterium tuberculosis (TB) in psoriasis patients receiving biologic therapies. METHODS A systematic review of PubMed, Google Scholar, ScienceDirect, Cochrane Library, and ClinicalTrials.gov databases was performed. Studies describing active TB in patients with psoriasis receiving biologic therapy from inception to May 31, 2018 were included. Clinical data as well as mortality rates were recorded. RESULTS Fifty-one studies were included, evaluating 78 patients with active TB: 11 prospective studies, 13 retrospective, and 27 case reports/series. Most patients (73%) with active TB were male, the mean age was 48 ± 13 years, and 85% were of European or Asian origin. Pre-treatment LTBI screening was negative for 63% of patients. Disease presented in 33% of patients within the first 3 months of treatment, and in 51% within the first 6 months. Most patients (72%) presented with extra-pulmonary TB, and 49% had disseminated disease. The mortality rate was 7%. LIMITATIONS Limitations of this review are its small sample size and inclusion of case reports. CONCLUSIONS Some patients develop active TB despite LTBI screening. Clinicians initiating biologic therapy in patients with psoriasis should be aware of the clinical features of active TB in this scenario.
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Patel S, Weaver MD, Roy S. Miliary tuberculosis and herpes pharyngitis after a trip to a developing country: dangers of biologics. BMJ Case Rep 2018; 2018:bcr-2018-224459. [PMID: 30279249 DOI: 10.1136/bcr-2018-224459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The use of biologic drugs has expanded since its introduction in the late 1990s. With growing medical use and newer biologic drugs in development, opportunistic infections like Mycobacterium tuberculosis remain important adverse effects. It carries major public health concerns, yet evidence-based clinical guidelines for more routine interval screening in patients taking immunosuppressants and exposed to tuberculosis (TB) are lacking. We illustrate a case of an elderly Indian-born man living in the USA with psoriatic arthritis who was on adalimumab for 10 years. He presented with disseminated TB and herpes simplex virus type 1 (HSV-1) pharyngitis, a year after an innocuous trip to India. Our case draws attention to the adverse effects of biologic drugs and highlights the importance of regular rescreening for a high-risk population. As the use of biologic treatment increases, physicians must be vigilant in more frequent screening, monitoring and identifying related opportunistic infections, notably M. tuberculosis infections.
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Affiliation(s)
- Sanket Patel
- Internal Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Martin Douglas Weaver
- Internal Medicine, Cooper University Hospital, Camden, New Jersey, USA.,Physical Medicine and Rehabilitation, Jackson Memorial Hospital, Miami, Florida, USA
| | - Satyajeet Roy
- Internal Medicine, Cooper University Hospital, Camden, New Jersey, USA
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Dantes E, Tofolean DE, Fildan AP, Craciun L, Dumea E, Tofolean IT, Mazilu L. Lethal disseminated tuberculosis in patients under biological treatment - two clinical cases and a short review. J Int Med Res 2018; 46:2961-2969. [PMID: 29792084 PMCID: PMC6124294 DOI: 10.1177/0300060518771273] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Tumour necrosis factor (TNF)-α inhibitors are highly used in Romania for the treatment of autoimmune disorders, such as rheumatoid arthritis (RA), psoriasis, inflammatory bowel diseases, and ankylosing spondylitis. Biological therapy using TNF-α inhibitors is very effective but is associated with an increased risk of opportunistic infections, including active tuberculosis. Here, two cases are presented of patients with RA and psoriasis under biological therapy who developed very aggressive forms of disseminated tuberculosis, with a rapid progression to death. The authors conclude that patients undergoing biological therapy require thorough evaluation prior to initiating treatment, followed by continuous and rigorous monitoring by a multidisciplinary team during biological treatment, particularly in countries with a high incidence of tuberculosis.
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Affiliation(s)
- Elena Dantes
- 1 Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania.,2 Pneumology Adults department I, Clinical Pulmonology Hospital of Constanta, Constanta, Romania
| | - Doina Ecaterina Tofolean
- 1 Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania.,3 Department of Pulmonology, Constanta County Clinical Emergency Hospital 'St. Apostol Andrei', Constanta, Romania
| | - Ariadna Petronela Fildan
- 1 Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania.,4 Pneumology Adults department II, Clinical Pulmonology Hospital of Constanta, Constanta, Romania
| | - Liviu Craciun
- 1 Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania.,3 Department of Pulmonology, Constanta County Clinical Emergency Hospital 'St. Apostol Andrei', Constanta, Romania
| | - Elena Dumea
- 1 Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania.,5 Infectious Diseases Adults department I, Clinical Infectious Diseases Hospital of Constanta, Constanta, Romania
| | - Ioan Tiberiu Tofolean
- 1 Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania.,6 Department of Gastroenterology, Constanta County Clinical Emergency Hospital 'St. Apostol Andrei', Constanta, Romania
| | - Laura Mazilu
- 1 Faculty of Medicine, Ovidius University of Constanta, Constanta, Romania.,7 Department of Oncology, Constanta County Clinical Emergency Hospital 'St. Apostol Andrei', Constanta, Romania
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Ogata H, Watanabe M, Matsui T, Hase H, Okayasu M, Tsuchiya T, Shinmura Y, Hibi T. Safety of Adalimumab and Predictors of Adverse Events in 1693 Japanese Patients with Crohn's Disease. J Crohns Colitis 2016; 10:1033-41. [PMID: 26961546 PMCID: PMC5007524 DOI: 10.1093/ecco-jcc/jjw060] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Data from an all-cases post-marketing study were used to evaluate the safety and effectiveness of adalimumab in Japanese patients with Crohn's disease [CD]. METHODS Patients received adalimumab for 24 weeks. Data from all patients [n = 1693] were used for the safety assessment. Data from patients with CD activity index [CDAI] ≥ 150 at baseline were used for the effectiveness assessment. RESULTS The most frequent serious adverse drug reaction [ADR] was infection and infestations [6.6 events/100 patient-years]. The risk of serious infections increased in patients who had a history of malignancy and those with concomitant corticosteroid use. Of 415 patients who had switched from another anti-tumour necrosis factor alpha [TNFα] agent to adalimumab due to ADRs, 7.2% discontinued due to ADRs to adalimumab. Ten of 13 patients with a history of tuberculosis [TB] received prophylactic medication, and none developed TB. TB developed in one patient with no history of TB or anti-TB prophylaxis. Remission rates were 41.3% and 32.4% at 4 and 24 weeks, respectively. Remission rates did not differ between patients with and without concomitant use of immunomodulators. Predictive variables for increased effectiveness were CDAI ≤ 220 and disease duration of ≤ 2 years. Perianal lesions and loss of response to previous anti-TNFα agents affected effectiveness. CONCLUSIONS The most frequent serious ADR was infection. Adalimumab significantly reduced disease activity, without any unexpected ADRs. Development of active TB during adalimumab therapy can be prevented through TB screening and prophylaxis. In patients who switched from another anti-TNFα agent to adalimumab due to ADRs, adalimumab was well tolerated.
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Affiliation(s)
- Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | | | | | | | | | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato Institute Hospital Kitasato University, Tokyo, Japan
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Nakao A, Ishii H, Igata F, Kushima H, Fujita M, Hisano S, Watanabe K. Disseminated tuberculosis with acute respiratory distress syndrome lacking granuloma formation in the lung. J Infect Chemother 2016; 22:638-41. [PMID: 26972247 DOI: 10.1016/j.jiac.2016.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/20/2016] [Accepted: 02/07/2016] [Indexed: 11/30/2022]
Abstract
A 66-year-old woman, who had been treated with systemic corticosteroids for four months for vasculitis of unknown etiology, was referred to our department due to a fever, dyspnea and patchy ground-glass opacities on chest computed tomography. As transbronchial biopsy specimens were suggestive of interstitial pneumonia, the prescribed dose of corticosteroids was increased. However, the patient developed pyrexia and presented diffuse ground-glass attenuation in the lungs bilaterally. Antituberculous drugs were administered because a previous blood interferon-gamma release assay was positive, however, the patient died of severe respiratory failure within several days, and cultures of her blood, urine and bone marrow posthumously revealed Mycobacterium tuberculosis. An autopsy revealed multiple foci of air-space pneumonia containing numerous acid-fast bacilli without granuloma formation, accompanied by diffuse alveolar damage. An immunosuppressive condition might inhibit air-space pneumonia to become granulomatous inflammation as an initial stage of pulmonary tuberculosis.
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Affiliation(s)
- Akira Nakao
- Department of Respiratory Medicine, Fukuoka University Hospital, Japan
| | - Hiroshi Ishii
- Department of Respiratory Medicine, Fukuoka University Hospital, Japan.
| | - Fumiyasu Igata
- Department of Respiratory Medicine, Fukuoka University Hospital, Japan
| | - Hisako Kushima
- Department of Respiratory Medicine, Fukuoka University Hospital, Japan
| | - Masaki Fujita
- Department of Respiratory Medicine, Fukuoka University Hospital, Japan
| | - Satoshi Hisano
- Department of Pathology, Fukuoka University Hospital, Japan
| | - Kentaro Watanabe
- Department of Respiratory Medicine, Fukuoka University Hospital, Japan
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Hayashi M, Umezawa Y, Fukuchi O, Ito T, Saeki H, Nakagawa H. Efficacy and safety of ustekinumab treatment in elderly patients with psoriasis. J Dermatol 2016; 41:974-80. [PMID: 25346301 DOI: 10.1111/1346-8138.12653] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 08/27/2014] [Indexed: 12/17/2022]
Abstract
The ratio of the elderly among psoriasis patients has been increasing. However, satisfactory long-term management of psoriasis for the elderly is challenging because of the more frequent presence of comorbidities, and the higher risk of adverse events from systemic therapeutic agents than younger patients. The use of ustekinumab (UST) appears to be an appropriate systemic treatment because it is considered less likely to cause adverse events than other systemic treatments, as well as necessitating fewer hospital visits. Our retrospective study aimed to evaluate the efficacy and safety profile of UST in elderly patients with psoriasis. The study included 24 patients aged over 65 years (range, 65-88 years; mean, 73.1 years) with moderate to severe plaque psoriasis with impaired quality of life. Efficacy and safety were assessed over a 1-year period using the Psoriasis Area and Severity Index (PASI) and the Dermatology Live Quality Index (DLQI). The efficacy was evaluated by the proportion of subjects who achieved ≥75% reduction in PASI score (PASI 75). PASI 75 responses were 56.5% at week 16, 59.1% at week 28, and 60.0% at week 52. None of the patients developed any serious infection during the 1-year treatment. The mean DLQI score at weeks 0, 16, 28, and 52 was 7.8 ± 6.0, 2.5 ± 3.4, 1.4 ± 1.7, and 1.2 ± 1.7, respectively. UST showed sufficient efficacy for elderly patients with psoriasis without any serious infection over the 1-year treatment. Our results suggest that UST is the preferable agent for the treatment of elderly patients with psoriasis.
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Affiliation(s)
- Mitsuha Hayashi
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
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8
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Li CR, Mao QX, Chen M, Jia WX, Yao X, Feng SY, Jia H, Gong JQ, Yang XY. Acquired latent tuberculosis infection in psoriasis patients treated with etanercept in the People's Republic of China. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:5591-4. [PMID: 26508833 PMCID: PMC4610804 DOI: 10.2147/dddt.s87260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background TNF-α plays a key role in host defense against mycobacterial infection, and patients receiving TNF-α blocker treatment have increased susceptibility to tuberculosis disease. In the People’s Republic of China, an intermediate tuberculosis-burden country, the latent tuberculosis infection (LTBI) risk in patients with psoriasis who are treated with etanercept, the safest kind of TNF-α blocker, is unknown. Objectives This study reports the LTBI risk in patients with psoriasis after etanercept treatment and aims to answer the question of how often rescreening for LTBI should be done in order to reduce active tuberculosis infection of patients and further reduce the incidence of active tuberculosis disease. Patients and methods: This retrospective review evaluated patients with moderate-to-severe chronic plaque psoriasis between 2009 and 2013. All patients were excluded tuberculosis infection and received etanercept 25 mg twice weekly, then the patients were checked for LTBI 3 months after etanercept treatment to observe the incidence of LTBI and assess the need for rescreening for LTBI every 3 months. Results We retrospectively analyzed 192 patients with psoriasis with moderate-to-severe chronic plaque whose tuberculin skin test and chest X-rays were negative and who received etanercept 25 mg twice weekly. Eighteen of them were excluded because they received less than 3 months of etanercept therapy. After treatment with etanercept, four patients were found to have LTBI. Conclusion In this study, the incidence of LTBI after 3 months was four in 192 (2.1%), which is higher than the annual incidence of LTBI in the People’s Republic of China (0.72%), so LTBI could be expected to occur within 3 months in psoriasis patients on etanercept. Periodic screening for LTBI in the therapy course, as well as before initiating treatment, is necessary in those patients who use a TNF-α blocker. We recommend rescreening for LTBI every 3 months.
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Affiliation(s)
- Cheng-Rang Li
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Qiu-Xia Mao
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Min Chen
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Wei-Xue Jia
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Xu Yao
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Su-Ying Feng
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Hong Jia
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Juan-Qin Gong
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
| | - Xue-Yuan Yang
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, Jiangsu, People's Republic of China
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Sehgal VN, Pandhi D, Khurana A. Biologics in dermatology: adverse effects. Int J Dermatol 2015; 54:1442-60. [PMID: 26147909 DOI: 10.1111/ijd.12802] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 01/13/2014] [Accepted: 06/25/2014] [Indexed: 12/13/2022]
Abstract
Biologics are a group of drugs that precisely affect certain specific steps in the immune response and are an extremely useful group when used in an appropriate setting. However, their use can often be a double-edged sword. Careful patient selection and thorough knowledge of adverse effects is a key to their successful use in various disorders. The initial enthusiasm has gradually given way to a more cautious approach wherein a balance is sought between clinical usefulness and expected side effects. The adverse effects of the biologics most commonly used in dermatology have been carefully listed for ready reference. The plausible causes of the adverse reactions are succinctly outlined along with their incriminating factor(s). Besides, in brief, the attention has been focused on their management. The content should provide an essential didactic content for educating the practitioner.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences, and Associated Guru Teg Bahadur Hospital, Shahdara, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, Dr RML hospital and PGIMER, New Delhi, India
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Barry S. Tuberculosis risk and biological therapy for psoriasis. Br J Dermatol 2015; 172:1482-1483. [DOI: 10.1111/bjd.13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S. Barry
- Consultant Respiratory Physician; Department of Respiratory Medicine; University Hospital Llandough; Penlan Road Penarth Wales
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Deffert C, Cachat J, Krause KH. Phagocyte NADPH oxidase, chronic granulomatous disease and mycobacterial infections. Cell Microbiol 2014; 16:1168-78. [PMID: 24916152 DOI: 10.1111/cmi.12322] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 06/03/2014] [Accepted: 06/06/2014] [Indexed: 12/26/2022]
Abstract
Infection of humans with Mycobacterium tuberculosis remains frequent and may still lead to death. After primary infection, the immune system is often able to control M. tuberculosis infection over a prolonged latency period, but a decrease in immune function (from HIV to immunosenescence) leads to active disease. Available vaccines against tuberculosis are restricted to BCG, a live vaccine with an attenuated strain of M. bovis. Immunodeficiency may not only be associated with an increased risk of tuberculosis, but also with local or disseminated BCG infection. Genetic deficiency in the reactive oxygen species (ROS)-producing phagocyte NADPH oxidase NOX2 is called chronic granulomatous disease (CGD). CGD is among the most common primary immune deficiencies. Here we review our knowledge on the importance of NOX2-derived ROS in mycobacterial infection. A literature review suggests that human CGD patient frequently have an increased susceptibility to BCG and to M. tuberculosis. In vitro studies and experiments with CGD mice are incomplete and yielded - at least in part - contradictory results. Thus, although observations in human CGD patients leave little doubt about the role of NOX2 in the control of mycobacteria, further studies will be necessary to unequivocally define and understand the role of ROS.
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Affiliation(s)
- Christine Deffert
- Laboratory for Biological Fluids, University Hospitals and Faculty of Medicine of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, 14, Switzerland; Department of Pathology and Immunology, Medical Faculty and University of Geneva, 1211, Geneva, 4, Switzerland
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Solovan C, Chiticariu E. Psoriasis, anti-tumor necrosis factor therapy, and tuberculosis: report of three challenging cases and literature review. Infect Dis Ther 2013; 2:59-73. [PMID: 25135824 PMCID: PMC4108098 DOI: 10.1007/s40121-013-0003-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The era of biologic therapies has provided new options for the treatment of chronic plaque psoriasis. However, safety concerns have led to intensive screening and monitoring of patients receiving anti-tumor necrosis factor alpha (anti-TNF-alpha) agents. METHODS The authors describe the cases of three patients with moderate to severe psoriasis treated with anti-TNF agents, with challenging diagnostic and treatment aspects regarding tuberculosis (TB) infection, a serious adverse event associated with this type of treatment. The cases are discussed in the context of a comprehensive literature review describing the risk of TB associated with the use of TNF inhibitors. A critical review of the clinical trials that have tested the safety of these agents is also presented. RESULTS One patient, who tested negatively for latent TB infection (LTBI) during screening, developed active TB under adalimumab therapy. For two other patients the diagnosis and management of LTBI in relation to anti-TNF therapy represented a challenge. Although clinical trials involving the use of anti-TNF therapy for psoriasis haven't demonstrated a high TB incidence, active TB is continuously reported in association with this treatment. CONCLUSIONS Findings from clinical practice and the scientific literature indicate that anti-TNF therapies are associated with an increased risk of TB, and close monitoring of patients is needed.
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Affiliation(s)
- Caius Solovan
- Department of Dermatology, University of Medicine and Pharmacy “Victor Babes” Timisoara, Marasesti 5, 300077 Timisoara, Romania
| | - Elena Chiticariu
- Department of Dermatology, University of Medicine and Pharmacy “Victor Babes” Timisoara, Marasesti 5, 300077 Timisoara, Romania
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Gin A, Dolianitis C. Multidrug resistant miliary tuberculosis during infliximab therapy despite tuberculosis screening. Australas J Dermatol 2013; 55:140-1. [DOI: 10.1111/ajd.12053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 03/07/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander Gin
- Department of Royal Melbourne Hospital; Melbourne Victoria Australia
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Sánchez-Moya A, García-Doval I, Carretero G, Sánchez-Carazo J, Ferrandiz C, Herrera Ceballos E, Alsina M, Ferrán M, López-Estebaranz JL, Gómez-García F, De la Cueva Dobao P, Carrascosa JM, Vanaclocha F, Belinchón I, Peral F, Dauden E. Latent tuberculosis infection and active tuberculosis in patients with psoriasis: a study on the incidence of tuberculosis and the prevalence of latent tuberculosis disease in patients with moderate-severe psoriasis in Spain. BIOBADADERM registry. J Eur Acad Dermatol Venereol 2012; 27:1366-74. [DOI: 10.1111/jdv.12011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Tsai TF, Ho V, Song M, Szapary P, Kato T, Wasfi Y, Li S, Shen Y, Leonardi C. The safety of ustekinumab treatment in patients with moderate-to-severe psoriasis and latent tuberculosis infection. Br J Dermatol 2012; 167:1145-52. [DOI: 10.1111/j.1365-2133.2012.11142.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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O’Neill ID, Scully C. Biologics in oral medicine: principles of use and practical considerations. Oral Dis 2012; 18:525-36. [DOI: 10.1111/j.1601-0825.2012.01919.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Redighieri IP, Maia TDC, Nadal MA, Caliman TRL, Ruiz MDFMA, Petri V. Erythrodermic psoriasis with regression after prophylaxis with isoniazid and antidepressant therapy: case report. An Bras Dermatol 2012; 86:S141-3. [PMID: 22068795 DOI: 10.1590/s0365-05962011000700037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 12/08/2011] [Indexed: 01/08/2023] Open
Abstract
An 83 year old woman, exhibiting severe psoriasis, was treated conventionally (phototherapy, acitretin, and cyclosporine). After poor clinical results and significant changes in laboratory procedures, those treatments were suspended. She was then being prepared to be submitted to biological treatment, when preliminary results disclosed a 30 mm PPD. Complete improvement occurred [only] after introducing prophylactic therapy for tuberculosis and anti-depressive medication.
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Girolomoni G, Altomare G, Ayala F, Berardesca E, Calzavara-Pinton P, Chimenti S, Peserico A, Puglisi Guerra A, Vena GA. Safety of anti-TNFα agents in the treatment of psoriasis and psoriatic arthritis. Immunopharmacol Immunotoxicol 2012; 34:548-60. [DOI: 10.3109/08923973.2011.653646] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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De Mozzi P, Johnston G, Alexandroff A. Psoriasis: an evidence-based update. Report of the 9th Evidenced Based Update Meeting, 12 May 2011, Loughborough, U.K. Br J Dermatol 2012; 166:252-60. [DOI: 10.1111/j.1365-2133.2011.10767.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Herrier RN. Advances in the treatment of moderate-to-severe plaque psoriasis. Am J Health Syst Pharm 2011; 68:795-806. [PMID: 21515863 DOI: 10.2146/ajhp100227] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Advances in the treatment of moderate-to-severe plaque psoriasis, including new biological agents and related drugs, are reviewed. SUMMARY Most patients with psoriasis have mild disease that can be treated with topical agents alone; however, over one third of patients have more-extensive disease, called moderate-to-severe plaque psoriasis. Although effective, traditional therapies, including methotrexate, cyclosporine, acitretin, and phototherapy, have serious adverse effects that limit both the initiation and duration of treatment, necessitating sequential treatment regimens. With the increasing knowledge of the immune nature of the disease, biological agents that target T lymphocytes, tumor necrosis factor (TNF)-α, interleukin (IL)-12, and IL-23 have been used successfully in moderate-to-severe psoriasis. Etanercept, adalimumab, and infliximab are also highly effective in the treatment of moderate-to-severe plaque psoriasis. Ustekinumab, a new agent that targets IL-12 and IL-23, was approved for marketing in 2009 and offers similar efficacy and safety profiles to the anti-TNF agents. While the rapid onset and apparent lack of long-term toxicity of biological agents make them major advances in the treatment of more severe forms of psoriasis, the lack of extensive experience with these agents in patients with psoriasis leaves several unresolved issues that must be addressed before their exact place in therapy can be determined. CONCLUSION With the development of biological therapies over the past 10 years, health care providers have a much broader choice of highly effective agents with which to treat patients suffering from moderate-to-severe plaque psoriasis. Though costly to use, biological agents offer considerable advantages over previously available systemic therapies.
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Affiliation(s)
- Richard N Herrier
- College of Pharmacy, University of Arizona, Tucson, AZ 85721-0202, USA.
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Chiang YZ, Panting K, Dever B, Parslew RAG. Clinical applicability of T-cell interferon-a release assay for tumour necrosis factor-a inhibitor therapy in severe psoriasis. Clin Exp Dermatol 2011; 36:39-41. [PMID: 20456401 DOI: 10.1111/j.1365-2230.2010.03850.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Many studies have found that screening and treatment of latent tuberculosis (TB) before starting treatment with tumour necrosis factor (TNF)-a inhibitors reduces associated TB infections. The new T-cell interferon-a release assay (TIGRA), is more specific and sensitive for detection of latent TB compared with the tuberculin skin test (TST). We report results of TIGRA in our first 63 patients commencing TNF-a inhibitors for severe psoriasis. Of the 63 patients, 5 (7.9%) had a positive TIGRA result and were started on treatment for latent TB. We found that the only risk factor for TB associated with a positive TIGRA was a history of travel to countries with high TB incidence. To our knowledge, this is the first study to identify the background risk (7.9%) of latent TB in an endemic UK population. This result emphasizes the importance of TIGRA testing to reduce the risk of TB in patients treated with TNF-a inhibitor.
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Affiliation(s)
- Y Z Chiang
- Department of Dermatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
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Duarte AA, Chehin FB. Psoríase moderada a grave tratada com infliximabe em 53 pacientes: perfil dos pacientes, eficácia e efeitos adversos. An Bras Dermatol 2011; 86:257-63. [DOI: 10.1590/s0365-05962011000200008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 04/06/2010] [Indexed: 12/29/2022] Open
Abstract
FUNDAMENTOS: A psoríase leva a um impacto negativo significativo na qualidade de vida e está associada a comorbidades. A atividade inflamatória das placas psoríacas se inicia, em parte, pela ativação de linfócitos Th1, que liberam citocinas pró-inflamatórias, como TNF alfa. Infliximabe neutraliza a atividade biológica do TNF alfa. Reações adversas que ocorrem durante a infusão e até 24 horas após são chamadas de agudas. Reações tardias ocorrem entre 24 horas e 14 dias após infusão. OBJETIVO: Avaliar o perfil dos pacientes com psoríase moderada a grave e resistente ao tratamento convencional, bem como as reações adversas ao infliximabe. MÉTODO: Foram tratados com infliximabe 53 pacientes: 40 homens e 13 mulheres. A dose utilizada foi 5 mg/kg nas semanas 0, 2 e 6 (fase de indução), seguida da fase de manutenção a cada oito semanas. RESULTADO: Dentre os 53 pacientes, seis se submeteram apenas à fase de indução, obtiveram Pasi 90-100 e não receberam mais a droga. Quarenta e sete pacientes continuaram recebendo a medicação por pelo menos dois, três anos. Deles, 55,3% (26) apresentaram algum efeito adverso. Os efeitos adversos precoces foram observados em 34% dos pacientes, e os tardios, em 36,1% dos pacientes. Foi encontrada uma prevalência de 57,4% de comorbidades nesses pacientes. CONCLUSÃO: O infliximabe mostrou-se seguro e eficaz no presente estudo. Dentre as comorbidades associadas aos pacientes neste estudo, a obesidade se relacionou com uma resposta mais tardia e menos eficiente. Efeitos adversos precoces e tardios, quando bem monitorados, não impedem a manutenção da terapêutica e não expõem os pacientes a riscos não controlados.
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Chiu HY, Hsueh PR, Tsai TF. Clinical experience of QuantiFERON(®) -TB Gold testing in patients with psoriasis treated with tumour necrosis factor blockers in Taiwan. Br J Dermatol 2011; 164:553-9. [PMID: 21083541 DOI: 10.1111/j.1365-2133.2010.10137.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In Taiwan, an intermediate tuberculosis burden country, around 9·3% of patients with rheumatoid arthritis treated with adalimumab develop tuberculosis despite prescreening with the tuberculin skin test. Within the Asia-Pacific region, the tuberculosis risk in patients with psoriasis who use tumour necrosis factor (TNF) blockers is unknown. OBJECTIVES This study reports the use of QuantiFERON(®) -TB Gold (QFT-G) (Cellestis, Melbourne, Vic., Australia) as a screening method for latent tuberculosis infection (LTBI) in patients with psoriasis. METHODS This retrospective review evaluated 216 patients with psoriasis in whom TNF blockers were considered between 2004 and 2009 in a tertiary referral hospital in Taiwan. Beginning in 2007, QFT-G was performed on all patients who were candidates for TNF blockers. RESULTS Seventeen patients who used TNF blockers for less than 4 weeks were excluded. Of the 147 assessed patients receiving TNF blockers, 110 (75%) underwent QFT-G tests. A total of 126 (86%) patients used etanercept and 40 (27%) patients used adalimumab. Nineteen patients switched between both. Overall, patients had a median of 24 weeks (range 4-307) exposure to TNF blockers. Twelve patients (11%) who were treated with TNF blockers and eight (15%) without TNF blockers had positive QFT-G results. Of all TNF blocker users, only one patient (0·68%) developed tuberculosis. CONCLUSIONS QFT-G can be used to screen for LTBI in a tuberculosis endemic area where bacille Calmette-Guérin vaccination coverage is high. Isoniazid prophylaxis is recommended for those who have positive QFT-G test results.
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Affiliation(s)
- H-Y Chiu
- Department of Dermatology National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Sánchez-Moya A, Daudén E. Diagnosing latent tuberculosis infection in patients with psoriasis under antitumour necrosis factor-α treatment: every new solution breeds new doubts. Br J Dermatol 2010; 164:208-9. [DOI: 10.1111/j.1365-2133.2010.10028.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sánchez-Moya AI, Dauden E. Incidence of tuberculosis infection in psoriatic patients on anti-TNF therapy: report of a case series with 144 patients. J Eur Acad Dermatol Venereol 2010; 25:730-3. [DOI: 10.1111/j.1468-3083.2010.03836.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fraser SJ, Hill AT, McKay DA, Reid WA, Mathers ME, MacDougall G, Schofield OMV. Cutaneous tuberculosis revealed by infliximab therapy for presumed sarcoidosis. Clin Exp Dermatol 2010; 35:e141-2. [DOI: 10.1111/j.1365-2230.2009.03675.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Patients with inflammatory bowel disease (IBD) often rely on their gastroenterologist for healthcare maintenance. In addition, the gastroenterologist also provides guidance to the patient's primary care physician on a broad range of issues such as vaccinations, osteoporosis screening, and cancer/dysplasia surveillance. Appropriate vaccinations should be administered to patients with IBD, particularly those likely to receive immunosuppression. Live virus vaccines are not appropriate for patients on immunosuppressive therapy, and therefore should be anticipated and given prior to initiating immunosuppression. Screening for osteoporosis is based on a combination of individual risk factors, but a history of prolonged (>3 months) steroid use over 10 mg is reason enough to obtain dual-energy x-ray absorptiometry scanning. Smoking cessation also falls within the realm of the gastroenterologist, as current smoking has a negative impact on Crohn's disease and cessation can be related to exacerbation in ulcerative colitis. Cancer screening includes not only colorectal cancer, but discussion regarding cervical dysplasia, skin cancer, and prostate cancer. Other primary care issues include hypertension and cholesterol monitoring, depression, and ocular health. A comprehensive understanding of all of the issues that can affect a patient with IBD throughout their life cycle is important, as it can impact their natural history, medication decisions, and overall outcomes.
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Affiliation(s)
- Maria Moscandrew
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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