Developing of Granulomatosis with Polyangiitis during Etanercept Therapy

Vasculitis induced by biological agents used in rheumatology practice: A systematic review

Objectives: Biological medications have been used with an increasing frequency to treat rheumatological diseases. Autoimmune events can be induced by these drugs, such as psoriasiform lesions, alopecia, lupus and, vasculitis, which more often affects the skin (small-sized vessels) and eventually other organs. In this review, we describe the clinical profile of patients with vasculitis induced by the main biological agents used in rheumatology.

Patients and methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The PubMed database was used for searching eligible articles. We included case reports, case series, and letter to the editor of patients on anti-tumor necrosis factor-alpha (anti-TNF-a) molecules, as well as tocilizumab, ustekinumab, secukinumab, rituximab, and abatacept, who had vasculitis induced by these agents.

Results: Eighty-one articles were included for final analysis (n=89). Twenty-seven patients were using infliximab, 20 adalimumab, 18 etanercept, seven secukinumab, four certolizumab, four rituximab, three golimumab, three ustekinumab, two abatacept, and one tocilizumab. Unspecific leukocytoclastic vasculitis (LCV) was the most common type of vasculitis (n=37), followed by anti-neutrophil cytoplasmic antibody (ANCA)- associated vasculitis (n=16). The medication was replaced with another biological molecule in 23 cases, with only four relapses. In six cases, the biological was maintained, but vasculitis worsened/persisted in one case, being necessary drug removal.

Conclusion: Infections, infusion reaction, cancer, and autoimmune events are well-known side effects of biological therapy. This review demonstrates that vasculitis is another adverse effect of this type of therapy, particularly the anti-TNF-a molecules, and LCV the most reported type of vasculitis.

Adalimumab-induced Anti-neutrophilic Cytoplasmic Antibody Vasculitis: A Rare Complication of an Increasingly Common Treatment

Tumor necrosis factor (TNF) inhibitors are used for treatment of different autoimmune diseases. Interestingly they are also being noted to cause autoimmune side effects such as vasculitis, systemic lupus erythematosus, interstitial lung disease, etc. We describe one such case of granuloma annulare being treated with Adalimumab, who then developed pulmonary-renal syndrome form anti-neutrophilic cytoplasmic antibody (ANCA)-induced vasculitis. This was treated with steroids and immunosuppression, as well as discontinuation of the TNF inhibitor. However, he remains dependant on dialysis and immunosuppression. In this article, we review the existing literature on clinical presentation and course of TNF inhibitors-induced ANCA vasculitis. We also discuss the underlying mechanisms thought to be responsible for this.

Drug safety and immunogenicity of tumour necrosis factor inhibitors: the story so far

TNF-α inhibitor (TNFi) therapies have transformed the treatment of several rheumatic musculoskeletal diseases. However, the majority of TNFi's are immunogenic and consequent anti-drug antibodies formation can impact on both treatment efficacy and safety. Several controversies exist in the area of immunogenicity of TNFis and drug safety. While anti-drug antibodies to TNFis have been described in association with infusion reactions; serious adverse events (AEs) such as thromboembolic events, lupus-like syndrome, paradoxical AEs, for example, vasculitis-like events and other autoimmune manifestations have also been reported. The expansion of the biologic armamentarium, new treatment strategies such as introduction/switching to biosimilars and cost-saving approaches such as TNFi tapering, may all have a potential impact on immunogenicity and clinical sequelae. In this review we evaluate how evolution of biologics relates to drug safety and immunogenicity, appraise relevant evidence from trials, spontaneous pharmacovigilance and observational studies and outline the areas of uncertainty that still exist.

Association of ANCA associated vasculitis and rheumatoid arthritis: a lesser recognized overlap syndrome

BACKGROUND

ANCA associated vasculitis (AAV) is an autoimmune disease with significant morbidity and mortality, in which diagnostic delay is associated with worse outcomes. AAV is rarely found in association with other immune mediated diseases. Early recognition of such overlaps enables more timely diagnosis and may impact on disease outcome. We reviewed cases of AAV in which there was an overlap with rheumatoid arthritis (RA).

METHODS

We performed a retrospective analysis of our vasculitis database for patients who had a diagnosis of AAV and RA, and a literature search to find other reported cases of this overlap syndrome.

RESULTS

We found six subjects who had a diagnosis of RA and developed AAV at a median of 10.5 years (range 4-43 years) after the diagnosis of RA. They had been treated with a mean of 2 disease modifying drugs (0-4) and all had evidence of renal involvement with median creatinine of 227 μmol/l (range 128-700 μmol/l). Only one had a diagnosis of granulomatosis with polyangiitis, while the rest had a clinical diagnosis of microscopic polyangiitis. Half of the patients had positive rheumatoid factor (RhF) at the time of vasculitis diagnosis, three had MPO-ANCA, one PR3-ANCA, and two had ANCA-negative pauci-immune vasculitis. Additionally, we found 29 other cases reported of this overlap, which also most frequently presented with vasculitic renal manifestations, and were frequently RhF positive at the time of AAV diagnosis.

CONCLUSIONS

AAV occurs in subjects with RA rarely, and often with significant delay from the first rheumatological manifestations. Renal involvement is common.