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Neema S, Kothari R, Rout A, Mani S, Bhatt S, Sandhu S. Systemic treatment of psoriasis in special population. Indian J Dermatol Venereol Leprol 2023; 0:1-8. [PMID: 37317756 DOI: 10.25259/ijdvl_7_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/21/2023] [Indexed: 06/16/2023]
Abstract
Psoriasis is a common skin disorder affecting approximately 1% of the general population. The treatment of psoriasis depends on the body surface area involvement, quality of life impairment and associated co-morbidities. Special population comprising of pregnant women, lactating mothers, elderly individuals and children, is more vulnerable. They are not included in drug trials; rendering the data for use of systemic treatment scant and is mainly based on anecdotal evidence. In this narrative review, we discuss systemic treatment options in this special population. Though couples planning a family are not considered a special population, they form a subset that require special therapeutic consideration and have also been included in this review.
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Affiliation(s)
| | - Rohit Kothari
- Department of Dermatology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | | | - Siddharth Mani
- Department of Dermatology, INHS Sanjivani Kochi, Kerala, India
| | - Siddharth Bhatt
- Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
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Jahnich N, Arkwright PD. Regional risk of tuberculosis and viral hepatitis with tumor necrosis factor-alpha inhibitor treatment: A systematic review. Front Pharmacol 2023; 14:1046306. [PMID: 36744250 PMCID: PMC9894886 DOI: 10.3389/fphar.2023.1046306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023] Open
Abstract
Background: TNFα inhibitors are regularly used to treat autoimmune diseases. Tuberculosis (TB) and viral hepatitis B are considered potential infectious complications, and screening and surveillance are therefore recommended. Current guidelines do not take into account regional differences in endemicity of these infections. Methods: A systematic literature review of TB and viral hepatitis in patients receiving TNFα-inhibitors was performed, searching in PubMed, Embase, MEDLINE and Web of Science databases. Studies were selected against predefined eligibility criteria and assessed using the Newcastle-Ottawa scale. The number of TB and viral hepatitis cases/1,000 TNFα-inhibitor patients were evaluated, and regional variation compared. Results: 105 observational studies involving over 140,000 patients were included. Overall, 1% of patients developed TB or viral hepatitis B. TB cases/1,000 TNFα-inhibitor patients were 4-fold higher in Asia, Africa, and South America than in Europe, North America, and Australasia where only 0%-0.4% of patients developed TB. Hepatitis B cases/1,000 patients were over 15-fold higher in countries with high prevalence (China, Taiwan, South Korea, Thailand) compared with low prevalence (p < 0.00001) where only 0.4% of patients developed hepatitis B. Only three of 143 patients developed viral hepatitis C, and there was insufficient data to allow regional sub-analysis. Conclusion: TB and viral hepatitis B infections in patients treated with TNFα inhibitors are largely confined to countries with high prevalence of these infections. As only 1/2,500 patients in low prevalence countries treated with TNFα inhibitors develop TB or viral hepatitis B, we suggest an individualized, risk-based approach, rather than universal screening for all patients.
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Affiliation(s)
| | - Peter D. Arkwright
- Lydia Becker Institute of Immunology and Inflammation, Manchester Incubator Building, University of Manchester, Manchester, United Kingdom
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MASTORINO L, DAPAVO P, TRUNFIO M, AVALLONE G, RUBATTO M, CALCAGNO A, RIBERO S, QUAGLINO P. Risk of Reactivation of Latent Tuberculosis in Psoriasis Patients on Biologic Therapies: A Retrospective Cohort from a Tertiary Care Centre in Northern Italy. Acta Derm Venereol 2022; 102:adv00821. [PMID: 36065745 PMCID: PMC9811291 DOI: 10.2340/actadv.v102.1982] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Psoriatic patients with latent tuberculosis infection and properly treated active tuberculosis need careful management when prescribing modern biological drugs. Although data and guidelines regarding tumour necrosis factor-α inhibitors advise caution and initiation of prophylactic therapy in patients with latent tuberculosis infection, the same indications do not seem to find equal force for interleukin (IL)-23 and IL-17 inhibitors. In order to evaluate the risk of reactivation in patients with latent tuberculosis infection or properly treated active tuberculosis, an observational retrospective study was conducted on the population referred to our centre at Dermatologic Clinic of University of Turin, Italy. In the last 10 years at the clinic 19 psoriatic patients were found to be at risk of tuberculosis reactivation: 10 patients were QuantiFERON- TB-positive at baseline, 2 became positive during treatment, 6 reported prior tuberculous infection, and 1 was QuantiFERON-TB-negative at baseline and developed disseminated tuberculosis during treatment with anti-tumour necrosis factor-α. Overall, 10.5% of this group of patients developed active tuberculosis; however, stratifying by biologic therapy, zero cases were observed among patients treated with anti-IL-17, -23, or -12/23 over a relatively long follow-up (48.1 months) A review of the available literature following our experience confirms the increased risk of tuberculosis reactivation with tumour necrosis factor-α inhibitors. Concerning anti-IL-23 and IL-17 drugs, available data showed high safety in patients at risk of tuberculosis reactivation. Screening of patients who should be taking IL-17 and IL-23 inhibitors is recommended for public health purposes. In case of a positive result with these therapies, consulting with an infectious diseases specialist is suggested in order to weigh up the risks and benefits of prophylactic treatment.
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Affiliation(s)
| | - Paolo DAPAVO
- Dermatology Clinic, Department of Medical Sciences
| | - Mattia TRUNFIO
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | | | - Andrea CALCAGNO
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
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Disseminated tuberculosis following negative QuantiFERON-TB gold tests during infliximab therapy: Implications for screening of hidradenitis suppurativa. JAAD Case Rep 2022; 29:76-79. [PMID: 36199671 PMCID: PMC9527620 DOI: 10.1016/j.jdcr.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Debnath P, Rathi PM. Vedolizumab in Inflammatory Bowel Disease: West versus East. Inflamm Intest Dis 2021; 6:1-17. [PMID: 33850834 DOI: 10.1159/000512805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/04/2020] [Indexed: 11/19/2022] Open
Abstract
Background Vedolizumab is a humanized immunoglobulin G1 monoclonal antibody, which binds to α4β7 integrin on T lymphocytes, thus disturbing the interaction with mucosal vascular addressin cell adhesion molecule 1 on the intestinal endothelial cells to interfere with lymphocyte trafficking to the gut. Summary Vedolizumab is a safe and effective drug to induce and maintain clinical remission in patients with Crohn's disease (CD) and ulcerative colitis (UC) in both clinical trials and real-world data. Various guidelines recommend vedolizumab as a first- or second-line treatment regimen for steroid-dependent, steroid, or immunomodulator refractory cases of UC and CD; however, it is more effective in anti-TNF-naive patients. The first head-to-head trial (VARSITY trial) comparing the efficacy of vedolizumab to adalimumab has shown better clinical remission and mucosal healing with vedolizumab. Key Messages In this review, we have discussed guidelines recommendation of vedolizumab use, as well as its safety data, use in special population, in presence of extraintestinal complications, therapeutic drug monitoring, data from Asian patients, along with other evolving concepts. Because of its excellent safety data and low immunogenicity, vedolizumab is an impressive option for patients with prior malignancy and less chance of reactivation of tuberculosis; however, cost remains an issue.
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Affiliation(s)
| | - Pravin M Rathi
- T.N.M.C. & B.Y.L. Nair Charitable Hospital, Mumbai, India
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Sarkar S, Panda S, Kim B, Raychaudhuri SK, Ghosh A, Raychaudhuri SP. Risk of tuberculosis with anti-tumor necrosis factor-alpha therapy in patients with psoriasis and psoriatic arthritis in Indian population. Indian J Dermatol Venereol Leprol 2020; 86:1-7. [PMID: 31719235 DOI: 10.4103/ijdvl.ijdvl_791_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Anti-tumor necrosis factor-alpha (TNF-α) immunotherapy has revolutionized the treatment of inflammatory diseases, such as psoriasis and psoriatic arthritis. However, a major concern is that patients receiving this therapy have an increased risk of infection, particularly of reactivation of latent tuberculosis (TB). There were an estimated 10.4 million new cases of tuberculosis in 2016, worldwide, and India has one of the largest TB case burden with an estimated incidence of 2.79 million cases of TB in the same year. Anti-TNF agents like etanercept and infliximab are available in India approved for psoriasis and psoriatic arthritis. But long-term use of these agents possesses a risk of reactivation of latent TB. In this review article, we assessed the risk of TB with anti-TNF therapy especially in patients with psoriasis and psoriatic arthritis in India. At the end of the article, we have also suggested a recommendation for screening of latent tuberculosis and its management, before starting anti-TNF-α therapy.
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Affiliation(s)
- Soumajyoti Sarkar
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, USA
| | - Saumya Panda
- Department of Dermatology, KPC Medical College, Kolkata, West Bengal, India
| | - Byungsoo Kim
- Department of Dermatology, School of Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea; Department of Dermatology, School of Medicine, University of California, Davis, CA, USA
| | | | - Asutosh Ghosh
- Department of Critical Care Medicine, IPGME and R, Kolkata, West Bengal, India
| | - Siba P Raychaudhuri
- Division of Rheumatology, Allergy and Clinical Immunology; Department of Dermatology, School of Medicine, University of California, Davis; VA Medical Center Sacramento, Mather, CA, USA
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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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Rodríguez-Jiménez P, Mir-Viladrich I, Chicharro P, Solano-López G, López-Longo F, Taxonera C, Sánchez-Martínez P, Martínez-Lacasa X, García-Gasalla M, Dorca J, Arias-Guillén M, García-García J, Dauden E. Consenso multidisciplinar sobre prevención y tratamiento de la tuberculosis en pacientes candidatos a tratamiento biológico. Adaptación al paciente dermatológico. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:584-601. [DOI: 10.1016/j.ad.2018.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 02/08/2023] Open
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Rodríguez-Jiménez P, Mir-Viladrich I, Chicharro P, Solano-López G, López-Longo F, Taxonera C, Sánchez-Martínez P, Martínez-Lacasa X, García-Gasalla M, Dorca J, Arias-Guillén M, García-García J, Dauden E. Prevention and treatment of tuberculosis infection in candidates for biologic therapy: A multidisciplinary consensus statement adapted to the dermatology patient. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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10
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Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies. J Am Acad Dermatol 2018; 80:251-265.e19. [PMID: 29928910 DOI: 10.1016/j.jaad.2018.06.027] [Citation(s) in RCA: 329] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 05/30/2018] [Accepted: 06/10/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Wide-ranging prevalence estimates of psoriatic arthritis (PsA) in patients with psoriasis have been reported. OBJECTIVES To assess the prevalence and incidence of PsA in patients with psoriasis. METHODS Two authors independently searched 3 databases for studies reporting on the prevalence or incidence of PsA in patients with psoriasis. A proportion meta-analysis was performed to calculate the pooled proportion estimates of PsA in patients with psoriasis. RESULTS A total of 266 studies examining 976,408 patients with psoriasis were included. Overall, the pooled proportion (95% confidence interval [CI]) of PsA among patients with psoriasis was 19.7% (95% CI, 18.5%-20.9%). In children and adolescents (<18 years of age), the pooled prevalence was 3.3% (95% CI, 2.1%-4.9%). The PsA prevalence was 22.7% (95% CI, 20.6%-25.0%) in European patients with psoriasis, 21.5% (95% CI, 15.4%-28.2%) in South American patients with psoriasis, 19.5% (95% CI, 17.1%-22.1%) in North American patients with psoriasis, 15.5% (95% CI, 0.009%-51.5%) in African patients with psoriasis, and 14.0% (95% CI, 95% CI, 11.7%-16.3%) in Asian patients with psoriasis. The prevalence of PsA was 23.8% (95% CI, 20.1%-27.6%) in studies in which the Classification Criteria for Psoriatic Arthritis were applied. The incidence of PsA among patients with psoriasis ranged from 0.27 to 2.7 per 100 person-years. LIMITATIONS Between-study heterogeneity may have affected the estimates. CONCLUSIONS We found that 1 in 4 patients with psoriasis have PsA. With the growing recognition of the Classification Criteria for Psoriatic Arthritis, more homogenous and comparable prevalence estimates are expected to be reported.
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Chen YH, de Carvalho HM, Kalyoncu U, Llamado LJQ, Solano G, Pedersen R, Lukina G, Lichauco JJ, Vasilescu RS. Tuberculosis and viral hepatitis infection in Eastern Europe, Asia, and Latin America: impact of tumor necrosis factor-α inhibitors in clinical practice. Biologics 2018; 12:1-9. [PMID: 29391775 PMCID: PMC5769557 DOI: 10.2147/btt.s148606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tumor necrosis factor-α (TNF-α) inhibitors are increasingly becoming the standard of care for treating a number of inflammatory diseases. However, treatment with TNF-α inhibitors carries an inherent risk of compromising the immune system, resulting in an increased susceptibility to infections and malignancies. This increased risk of infection is of particular concern in Asia, Eastern Europe, and Latin America where tuberculosis (TB) and viral hepatitis are endemic. In this brief review, we examine the literature and review the impact of TNF-α inhibitors on the incidence and the reactivation of latent disease with respect to TB, hepatitis C infection, and hepatitis B infection. Our findings show that TNF-α inhibitors are generally safe, if used with caution. Patients should be screened prior to the initiation of TNF-α inhibitor treatment and given prophylactic treatment if needed. In addition, patients should be monitored during treatment with TNF-α inhibitors and after treatment has stopped to ensure that infections, if detected, are treated promptly and effectively. Our analysis is consistent with other reports and guidelines.
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Affiliation(s)
- Yi-Hsing Chen
- Division of Allergy, Immunology, and Rheumatology, Taichung Veterans General Hospital, Taichung City, Taiwan
| | | | - Umut Kalyoncu
- Department of Internal Medicine, Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
| | | | | | | | | | - Juan J Lichauco
- Section of Rheumatology, Department of Medicine, St. Luke's Medical Center, Quezon City, Manila, Philippines
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Risk of active tuberculosis in patients with inflammatory arthritis receiving TNF inhibitors: a look beyond the baseline tuberculosis screening protocol. Clin Rheumatol 2017; 37:2391-2397. [PMID: 29150737 DOI: 10.1007/s10067-017-3916-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 10/26/2017] [Accepted: 11/10/2017] [Indexed: 12/21/2022]
Abstract
Tuberculosis (TB) is a major concern in patients receiving TNF inhibitors (TNFi). This study aimed to assess the incidence of active TB and the efficacy of TB prevention measures used over the years, and to determine risk factors for developing TB, in a single-centre cohort of patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) receiving TNFi. Data of all patients in whom treatment with TNFi was initiated in our rheumatology clinic until December 1st 2014 have been retrospectively analysed. The cohort was divided into 3 groups per the mandatory LTBI screening method at baseline: tuberculin skin test (TST) with a positive threshold of either 10 mm (group TST1), or 5 mm (group TST2), and QuantiFERON®-TB Gold test (group QFT). The incidence of active TB was analysed for each group and compared to TB incidence data in general population. Five hundred fifty patients were included (305 RA, 42 PsA, 203 AS); 97 patients belonged to the TST1, 229 to the TST2 and 224 to the QFT group. The number of active TB cases/time of exposure to TNFi (person-years, PY) was 8/593.5, 9/1044.0 and 3/555.3, respectively, accounting for an incidence of 1348.0, 862.1 and 540.2 cases per 105 PY. Active TB cases occurring in the first year of TNFi treatment (early TB) per total TB cases were only 3/8, 1/9 and 1/3, respectively, too few to identify statistically significant differences between the 3 LTBI screening protocols. However, less TB cases per total observation time were registered in the QFT group, probably due to the reduced duration of exposure to TNFi. All cases of active TB were registered among patients receiving monoclonal antibodies TNFi agents. We have found no significant risk factors for developing active TB. In our cohort, TB occurring after 1 year of TNFi treatment exceeds 'early TB', suggesting the necessity of further TB prevention measures besides baseline screening for LTBI.
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Yamamoto S, Nagatani K, Sato T, Iwamoto M, Takatori S, Minota S. Unaffected reaction level in tuberculin skin test by long-term therapy with tumor necrosis factor inhibitors for rheumatoid arthritis. Int J Rheum Dis 2017; 20:584-588. [PMID: 28524434 DOI: 10.1111/1756-185x.13101] [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] [Indexed: 11/28/2022]
Abstract
AIM The tuberculin skin test (TST) is used to diagnose tuberculosis; however, the influence of tumor necrosis factor (TNF) inhibitors on the test is unclear. This study investigated whether therapy with TNF inhibitors suppresses the TST reaction due to immunosuppression or whether the TST reaction increases due to reactivation of latent Mycobacterium tuberculosis infection. METHOD Ninety-one patients with rheumatoid arthritis receiving TNF inhibitors (40 using infliximab and 51 using etanercept) were studied. The TST was performed before starting TNF inhibitors (T1) and more than 1 year after starting them (T2). RESULTS At T1, the reaction was negative in 45 patients, weakly positive in 21 patients, moderately positive in 18 patients and strongly positive in seven patients, while the numbers at T2 were 44, 20, 16 and 11, respectively. There were no significant differences of the TST reaction between T1 and T2 in all patients (P = 0.657), patients using infliximab (P = 0.462) or patients using etanercept (P = 1.00). No patients with a strongly positive TST reaction at T1 became negative at T2. However, two patients who were negative at T1 became strongly positive at T2. Although they had no signs of M. tuberculosis infection, isoniazid prophylaxis was given. CONCLUSION The TST reaction was not suppressed after more than 1 year of therapy with TNF inhibitors. Patients in whom the TST reaction changes from negative to strongly positive may need appropriate prophylaxis.
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Affiliation(s)
- Shotaro Yamamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Katsuya Nagatani
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Takeo Sato
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masahiro Iwamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shino Takatori
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Seiji Minota
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Momose M, Asahina A, Hayashi M, Yanaba K, Umezawa Y, Nakagawa H. Biologic treatments for elderly patients with psoriasis. J Dermatol 2017; 44:1020-1023. [PMID: 28439956 DOI: 10.1111/1346-8138.13853] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 02/22/2017] [Indexed: 01/13/2023]
Abstract
The number of elderly patients with psoriasis is increasing in Japan. However, biologic treatment is generally considered to be challenging in elderly patients, due to their increased risk of complications compared with younger patients. Our retrospective study aimed to evaluate the safety profile and efficacy of biologics in senior elderly patients (≥75 years old) with psoriasis. The study involved a cohort of 27 patients aged 75-88 years who were being treated with biologics over a period of more than 1 year. Initial biologics administrated to were adalimumab (five cases) and ustekinumab (22 cases). Eight patients discontinued treatment: two developed cancer; one was transferred to hospital; and five others experienced either bone fracture, interstitial pneumonia, cerebral hemorrhage resulting in death, decrepitude or developed hepatopathy following prophylactic tuberculosis treatment. Efficacy, evaluated by the percentage of patients achieving 75% reduction of Psoriasis Area and Severity Index score, was 76.9% at week 16 (n = 26), 88.0% at week 24 (n = 25) and 90.5% at week 52 (n = 21). Biologic treatments thus show clear efficacy in elderly patients with psoriasis, however, the increased frequency of adverse events requires rigorous patient observation.
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Affiliation(s)
- Mami Momose
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Akihiko Asahina
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuha Hayashi
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichi Yanaba
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshinori Umezawa
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hidemi Nakagawa
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
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Cataño J, Morales M. Isoniazid toxicity and TB development during biological therapy of patients with psoriasis in Colombia. J DERMATOL TREAT 2016; 27:414-7. [PMID: 27003177 DOI: 10.3109/09546634.2016.1151857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background The use of biological therapy has been linked with an increased risk of tuberculosis (TB) reactivation. Objective The aim of this study was to present the follow-up results for Isoniazid (INH) chemoprophylaxis in patients with psoriasis receiving different biological therapies. Methods In this prospective observational study, patients with latent tuberculosis infection (LTBI) were given INH chemoprophylaxis between two and nine months prior to the beginning of biological therapy. All patients were followed up monthly for any signs or symptoms of active TB or INH toxicity. Results A total of 101 patients, 44.5% females, with a mean age of 46.9 ± 11.5 years (20-73) were enrolled. LTBI was identified in 100 patients (99%), of whom 81.2% completed nine months of chemoprophylaxis. Three patients (2.9%) developed active TB and 17 patients (16.8%) developed intolerance or toxicity related to INH. Conclusions Chemoprophylaxis with INH seems to be effective and safe for the prevention of most TB reactivations in individuals with LTBI receiving biological therapy, but toxicity must be monitored during follow-up.
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Affiliation(s)
- Juan Cataño
- a Infectious Diseases Section, Internal Medicine Department , University of Antioquia Medical School and Fundacion , Antioqueña de Infectologia , Medellín , Colombia ;,b Infectious Diseases Section , Las Vegas Clinic and Fundacion , Antioqueña de Infectologia , Medellín , Colombia
| | - Milena Morales
- b Infectious Diseases Section , Las Vegas Clinic and Fundacion , Antioqueña de Infectologia , Medellín , Colombia
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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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17
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Ribera M, Zulaica A, Pujol C, Alonso M, Rodriguez I, Garcia-Calvo C. Estimation of the prevalence of latent tuberculosis infection in patients with moderate to severe plaque psoriasis in Spain: The Latent study. ACTAS DERMO-SIFILIOGRAFICAS 2015. [DOI: 10.1016/j.adengl.2015.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ribera M, Zulaica A, Pujol C, Alonso ML, Rodriguez IM, Garcia-Calvo C. Estimation of the prevalence of latent tuberculosis infection in patients with moderate to severe plaque psoriasis in Spain: The Latent study. ACTAS DERMO-SIFILIOGRAFICAS 2015; 106:823-9. [PMID: 26381434 DOI: 10.1016/j.ad.2015.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 07/22/2015] [Accepted: 08/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Anti-tumor necrosis factor therapy for moderate to severe psoriasis can increase the risk of active tuberculosis in patients who have latent tuberculosis infection (LTBI). The main objective of this study was to estimate the prevalence of LTBI in patients with moderate to severe plaque psoriasis being treated in dermatology clinics in Spain. MATERIAL AND METHOD Non-interventional, cross-sectional, national epidemiological study conducted in Spain in 2011-2012. Patients with moderate to severe plaque psoriasis were included if they had undergone at least one tuberculin skin test (TST) and/or been evaluated with an interferon-γ release assay (IGRA) based on enzyme-linked immunosorbent assay (QuantiFERON(®) TB Gold In-Tube) in the 2 years preceding the study. RESULTS Data for 440 patients were valid for analysis. In total, 97.7% of the patients had undergone a TST, with a positive result in 23%. Of the 238 patients in whom the initial result was negative, 5% converted to positive on re-testing for a booster effect. IGRA results were available for 16.8%, 20.5% of them positive. Two of the patients with positive IGRA results had a negative TST. The prevalence of LTBI in the whole sample was 26.6%. The degree of concordance between the TST and the IGRA was moderate (κ=0.516; P<.001). CONCLUSIONS The prevalence of LTBI in this study was similar to previous estimates for Spain.
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Affiliation(s)
- M Ribera
- Servicio de Dermatología, Hospital Universitari de Sabadell-Corporació Parc Taulí, Sabadell, Barcelona, España
| | - A Zulaica
- Servicio de Dermatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - C Pujol
- Servicio de Dermatología, Hospital Universitario La Fe, Valencia, España
| | - M L Alonso
- Servicio de Dermatología, Hospital Universitario La Paz, Madrid, España
| | - I M Rodriguez
- Servicio de Dermatología, Complejo Hospital Universitario de Badajoz, Badajoz, España
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Ahn CS, Dothard EH, Garner ML, Feldman SR, Huang WW. To test or not to test? An updated evidence-based assessment of the value of screening and monitoring tests when using systemic biologic agents to treat psoriasis and psoriatic arthritis. J Am Acad Dermatol 2015; 73:420-8.e1. [PMID: 26184440 DOI: 10.1016/j.jaad.2015.06.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Safety profiles of systemic biologic agents for the treatment of psoriasis and psoriatic arthritis (PsA) encompass a wide spectrum of adverse events. To date, no uniform evidence-based guidelines exist regarding screening and monitoring patients who are undergoing biologic therapy. OBJECTIVE We sought to identify studies evaluating screening and monitoring tests in the treatment of psoriasis and PsA with systemic biologic agents, and to propose evidence-based practical guidelines. METHODS The MEDLINE database was searched to identify data on risks associated with adalimumab, etanercept, infliximab, and ustekinumab. Articles were reviewed and graded according to methods developed by the US Preventative Services Task Force. RESULTS Evidence was strongest (grade B) for tuberculosis screening. Interferon-gamma release assay was preferable to tuberculin skin testing. Among known hepatitis B virus carriers, the evidence grade was C for monitoring liver function tests and viral load. LIMITATIONS This study was limited by the lack of high-quality controlled trials evaluating screening and monitoring tests in patients treated with biologic agents. CONCLUSIONS Baseline tuberculosis testing remains the only screening test with strong evidence to support its practice. Other screening and monitoring tests commonly performed in patients who are taking biologic agents are supported only in certain clinical settings or lack evidence to support or recommend against their practice.
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Affiliation(s)
- Christine S Ahn
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Emily H Dothard
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael L Garner
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Steven R Feldman
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - William W Huang
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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Gisondi P, Cazzaniga S, Chimenti S, Maccarone M, Picardo M, Girolomoni G, Naldi L. Latent tuberculosis infection in patients with chronic plaque psoriasis: evidence from the Italian Psocare Registry. Br J Dermatol 2015; 172:1613-1620. [DOI: 10.1111/bjd.13539] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 11/27/2022]
Affiliation(s)
- P. Gisondi
- Department of Medicine; Section of Dermatology and Venereology; University of Verona; Piazzale A. Stefani 1 I-37126 Verona Italy
| | - S. Cazzaniga
- GISED Study Centre; Ospedali Riuniti; Bergamo Italy
| | - S. Chimenti
- Department of Dermatology; University of Rome ‘Tor Vergata’; Rome Italy
| | - M. Maccarone
- Italian Psoriatic Patient Association (ADIPSO); Rome Italy
| | - M. Picardo
- Laboratory of Cutaneous Physiopathology; San Gallicano Dermatological Institute; Rome Italy
| | - G. Girolomoni
- Department of Medicine; Section of Dermatology and Venereology; University of Verona; Piazzale A. Stefani 1 I-37126 Verona Italy
| | - L. Naldi
- GISED Study Centre; Ospedali Riuniti; Bergamo Italy
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21
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Ergun T, Seckin D, Baskan Bulbul E, Onsun N, Ozgen Z, Unalan P, Alpsoy E, Karakurt S. The risk of tuberculosis in patients with psoriasis treated with anti-tumor necrosis factor agents. Int J Dermatol 2015; 54:594-9. [PMID: 25753908 DOI: 10.1111/ijd.12628] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tumor necrosis factor-alpha (TNF-α) antagonist treatment is associated with 1.6 to 27 times higher risk of tuberculosis (TB). OBJECTIVE To find TB incidence of psoriasis patients treated with TNF- α antagonists and define risk factors related with this condition in a country with moderately high risk of TB. METHODS Three hundred seventy psoriasis patients treated by anti-TNF agents in four referral centers were included. The data on the characteristics of the patients, TB history, tuberculosis skin test results, anti-TNF agent type and exposure time, localization of TB, and isoniazide prophylaxis state were analyzed. RESULTS Four patients (1.08%) developed TB, three pulmonary and one gastrointestinal, 2-23 months after initiating anti-TNF agents. Other than the patient with gastrointestinal TB, who was using methotrexate and corticosteroid concomitantly, none had contributing risk factors for TB. Two patients developed pulmonary TB in spite of chemoprophylaxis. Three patients with pulmonary TB completely recovered following antiTB treatment whereas patients with gastroinrestinal TB developed renal failure. LIMITATIONS The major limitation of the study is the lack of a diseased control group, which enables us to compare the risk of psoriatics with that of patients having other inflammatory diseases. CONCLUSION Tuberculosis is a rare but a severe complication of anti-TNF treatment and may develop in spite of chemoprophylaxis. The risk of TB in psoriasis patients in the present study is comparable to literature mostly based on rheumatology patients.
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Affiliation(s)
- Tulin Ergun
- Department of Dermatology, Marmara University School of Medicine, Istanbul, Turkey
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Gisondi P, Pezzolo E, Lo Cascio G, Girolomoni G. Latent tuberculosis infection in patients with chronic plaque psoriasis who are candidates for biological therapy. Br J Dermatol 2014; 171:884-90. [DOI: 10.1111/bjd.13130] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2014] [Indexed: 01/02/2023]
Affiliation(s)
- P. Gisondi
- Department of Medicine Section of Dermatology and Venereology University of Verona I‐37126 Verona Italy
| | - E. Pezzolo
- Department of Medicine Section of Dermatology and Venereology University of Verona I‐37126 Verona Italy
| | - G. Lo Cascio
- Department of Pathology and Diagnostics Section of Microbiology University of Verona I‐37126 Verona Italy
| | - G. Girolomoni
- Department of Medicine Section of Dermatology and Venereology University of Verona I‐37126 Verona Italy
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Sanchez-Carazo JL, López-Estebaranz JL, Guisado C. Comorbidities and health-related quality of life in Spanish patients with moderate to severe psoriasis: A cross-sectional study (Arizona study). J Dermatol 2014; 41:673-8. [DOI: 10.1111/1346-8138.12465] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/12/2014] [Indexed: 12/21/2022]
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Saraceno R, Specchio F, Chiricozzi A, Sarmati L, Amicosante M, Chimenti MS, Chimenti S. Usefulness of QuantiFERON®-TB Gold test in psoriatic patients under treatment with tumour necrosis factor blockers. Expert Opin Biol Ther 2013; 14:151-6. [DOI: 10.1517/14712598.2014.860441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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López-Ferrer A, Vilarrasa E, Gich I, Puig L. Adalimumab for the treatment of psoriasis in real life: a retrospective cohort of 119 patients at a single Spanish centre. Br J Dermatol 2013; 169:1141-7. [DOI: 10.1111/bjd.12543] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2013] [Indexed: 02/06/2023]
Affiliation(s)
- A. López-Ferrer
- Department of Dermatology; Hospital de la Santa Creu i Sant Pau; Universitat Autònoma de Barcelona; Sant Antoni Maria Claret 167 08025 Barcelona Catalonia Spain
| | - E. Vilarrasa
- Department of Dermatology; Hospital de la Santa Creu i Sant Pau; Universitat Autònoma de Barcelona; Sant Antoni Maria Claret 167 08025 Barcelona Catalonia Spain
| | - I.J. Gich
- Department of Clinical Epidemiology and Public Health; Hospital de la Santa Creu i Sant Pau; Universitat Autònoma de Barcelona; Sant Antoni Maria Claret 167 08025 Barcelona Catalonia Spain
| | - L. Puig
- Department of Dermatology; Hospital de la Santa Creu i Sant Pau; Universitat Autònoma de Barcelona; Sant Antoni Maria Claret 167 08025 Barcelona Catalonia Spain
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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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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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28
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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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Balato N, Di Costanzo L, Ayala F, Balato A, Sanduzzi A, Bocchino M. Psoriatic disease and tuberculosis nowadays. Clin Dev Immunol 2012; 2012:747204. [PMID: 22645622 PMCID: PMC3356875 DOI: 10.1155/2012/747204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 02/21/2012] [Indexed: 01/28/2023]
Abstract
Psoriasis is a chronic, relapsing and remitting inflammatory skin and joint disease that has a prevalence of 2-3% in the world's population, whereas of 1-2% in Europe. The traditional concept of psoriasis as the "healthy people's" disease has been recently revised because of ever-increasing reports of associations with various pathological conditions (hypertension, Crohn's disease, type II diabetes mellitus, obesity, dyslipidemia, metabolic syndrome, infectious conditions). Particularly, advances in psoriasis therapies have introduced biologic agents. All the tumor necrosis factor-alpha inhibitors are associated with an increased risk of developing active disease in patients with latent tuberculosis infection, because of TNF-α key role against Mycobacterium tuberculosis. For this reason, exclusion of active tuberculosis and treatment of latent tuberculosis infection are clinical imperatives prior to starting this therapy. Moreover active surveillance for a history of untreated or partially treated tuberculosis or latent form has already been shown to be effective in reducing the number of incident tuberculosis cases.
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Affiliation(s)
- Nicola Balato
- Department of Dermatology, University of Naples Federico II, Italy
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Puig L, Camacho Martínez FM, Gimeno Carpio E, López-Ávila A, García-Calvo C. Efficacy and Safety of Clinical Use of Etanercept for the Treatment of Moderate-to-Severe Psoriasis in Spain: Results of a Multicentric Prospective Study at 12 Months Follow-Up. Dermatology 2012; 225:220-30. [DOI: 10.1159/000343605] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 09/15/2012] [Indexed: 11/19/2022] Open
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Time for a change? Updated guidelines using interferon gamma release assays for detection of latent tuberculosis infection in the office setting. J Am Acad Dermatol 2012; 66:148-52. [DOI: 10.1016/j.jaad.2011.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 09/02/2011] [Accepted: 09/08/2011] [Indexed: 11/19/2022]
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