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Paradoxical Reactions Under TNF-Α Blocking Agents and Other Biological Agents Given for Chronic Immune- Mediated Diseases: an Analytical and Comprehensive Overview

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Paradoxical Reactions Under TNF-Α Blocking Agents and Other Biological Agents Given for Chronic Immune- Mediated Diseases: an Analytical and Comprehensive Overview Treatments RMD Open: first published as 10.1136/rmdopen-2015-000239 on 15 July 2016. Downloaded from REVIEW Paradoxical reactions under TNF-α blocking agents and other biological agents given for chronic immune- mediated diseases: an analytical and comprehensive overview Éric Toussirot,1,2,3,4 François Aubin5,6 To cite: Toussirot É, Aubin F. ABSTRACT Key messages Paradoxical reactions under Paradoxical adverse events (PAEs) have been reported α TNF- blocking agents and during biological treatment for chronic immune- other biological agents given What is already known about this subject? mediated diseases. PAEs are defined as the occurrence for chronic immune-mediated Different paradoxical adverse events have been diseases: an analytical and during biological agent therapy of a pathological described under biological agents, mainly tumour comprehensive overview. condition that usually responds to this class of drug. necrosis factor α inhibitors. RMD Open 2016;2:e000239. A wide range of PAEs have been reported including doi:10.1136/rmdopen-2015- dermatological, intestinal and ophthalmic conditions, What does this study add? 000239 mainly with antitumour necrosis factor α (TNF-α) A wide range of paradoxical adverse events have agents. True PAEs include psoriasis, Crohn’s disease been reported including dermatological, intestinal ▸ Prepublication history for and hidradenitis suppurativa. Other PAEs may be and ophthalmic conditions, but their relationship this paper is available online. qualified as borderline and include uveitis, scleritis, with the biological agent exposition remains still To view these files please sarcoidosis and other granulomatous diseases debated. visit the journal online (granuloma annulare, interstitial granulomatous (http://dx.doi.org/10.1136/ dermatitis), vasculitis, vitiligo and alopecia areata. How might this impact on clinical practice? http://rmdopen.bmj.com/ rmdopen-2015-000239). Proposed hypotheses to explain these PAEs include an The clinician must know these paradoxical adverse imbalance in cytokine production, the differential events as well as the therapeutic strategy to have Received 29 December 2015 immunological properties between the monoclonal when such event occurs in a patient under a bio- Revised 24 April 2016 α Accepted 28 April 2016 antibodies and TNF- soluble receptor, an unopposed logical agent. type I interferon production and a shift towards a Th1/Th2 profile. Data from registries suggest that the risk for paradoxical psoriasis is low and non- tumour necrosis factor α (TNF-α) blocking significant. We discuss management of these PAEs, agents are available: three monoclonal anti- on September 29, 2021 by guest. Protected copyright. which depends on the type and severity of the adverse bodies (infliximab, adalimumab, golimu- events, pre-existing treated conditions and the mab), a p75 TNF-α soluble receptor possibility of alternative therapeutic options for the ’ underlying disease. Paradoxical adverse events are not (etanercept) and a Fab fragment associated restricted to anti-TNF-α agents and close surveillance with a pegol molecule (certolizumab). With of new available biological drugs (anti-interleukin-17/ the improved understanding of the patho- 23, anti-integrin) is warranted in order to detect the physiology of immune-mediated diseases, occurrence of new or as yet undescribed events. new relevant therapeutic targets have been identified, leading to the development of new biological drugs. In this setting, The introduction of biological agents on the anti-CD20 (rituximab), anti-interleukin market has dramatically changed the thera- (IL)-1 (anakinra), anti-IL-6 (tocilizumab) peutic approach to a variety of systemic and a fusion protein inhibiting the costimula- immune-mediated diseases, such as chronic tory pathway (abatacept) have been devel- For numbered affiliations see fl end of article. in ammatory rheumatic diseases (rheuma- oped for the treatment of RA. It has also toid arthritis (RA) and spondyloarthritis been shown that the Th17/ IL-23 pathway fl Correspondence to (SpA)), plaque psoriasis and in ammatory plays an important role in psoriasis and Professor Éric Toussirot; bowel diseases (Crohn’s disease (CD) and psoriatic arthritis (PsA), and thus ustekinu- [email protected] ulcerative colitis (UC)). Currently, five mab, an anti-p40 IL-12/23 monoclonal Toussirot É, Aubin F. RMD Open 2016;2:e000239. doi:10.1136/rmdopen-2015-000239 1 RMD Open RMD Open: first published as 10.1136/rmdopen-2015-000239 on 15 July 2016. Downloaded from antibody, has become available. Vedolizumab is a new α β Table 1 Paradoxical conditions described under biological agent directed against the 4 7 integrin that biological agents given for immune-mediated diseases has been recently licensed in the treatment of CD. Intriguingly, unexpected side effects have been True PAE Borderline PAE reported with the use of biological agents in clinical Biological Biological practice. Indeed, dermatological, intestinal and ophthal- AE agent AE agent mological paradoxical adverse events (PAEs) have been Psoriasis Anti-TNF-α Uveitis Anti-TNF-α described, mainly with anti-TNF-α agents. In this review, Rituximab (etanercept) we will focus on the different PAEs that have been Tocilizumab described with anti-TNF-α and other biological agents. Ustekinumab Crohn’s Anti-TNF-α Scleritis Anti-TNF-α We will also attempt to analyse the potential mechanisms disease (etanercept) that may explain this immunological phenomenon, and fi and/or nally we propose management strategies. ulcerative colitis Hidradenitis Anti-TNF-α Sarcoidosis Anti-TNF-α DEFINITION AND GENERAL CONSIDERATIONS suppurativa (adalimumab) (etanercept) PAEs may be defined as the occurrence during therapy Rituximab with a biological agent, of a pathological condition that Granuloma Anti-TNF-α usually responds to this class of drug. In this regard, the annulare α incriminated biological agent must have previously Interstitial Anti-TNF- proven its efficacy in the treatment of the induced condi- granulomatous fi ‘ ’ dermatitis tion. In this case, the PAE is quali ed as true (or α “ ” Vasculitis Anti-TNF- authentic ). This is well illustrated by the onset of (de Alopecia areata Anti-TNF-α α 1 novo) psoriasis during anti-TNF- therapy. In parallel, Vitiligo Anti-TNF-α the biological agent may worsen a pre-existing condition ustekinumab α (for instance, psoriasis may worsen when an anti-TNF- AE adverse events; PAE, paradoxical adverse events; TNF, agent is started for psoriasis or PsA). In addition, some tumour necrosis factor. PAEs are in fact extra-articular manifestations of the disease (for instance, uveitis during anti-TNF-α therapy 3 ‘ ’ database. In a single primary referral centre in France, 12 for SpA). On the other hand, borderline PAEs can be PAEs (psoriasis, acute anterior uveitis and inflammatory fi de ned as the development of certain immune-mediated bowel disease (IBD)) were reported among 296 patients conditions that are observed during a biological treat- fl http://rmdopen.bmj.com/ fi fi with SpA treated by in iximab, etanercept or adalimu- ment that has not proven its ef cacy in this speci c condi- mab, giving an overall frequency of 1.9/100 patient-years.4 tion, despite a rationale for its use. For instance, sarcoidosis may occur during anti-TNF-α therapy, but anti-TNF-α agents are not approved for the treatment of ‘TRUE’ PAES this granulomatous disease.2 On the contrary, some spe- One of the most frequently described cutaneous PAEs is cific adverse events occurring with biological drugs (for psoriasis.5 instance, demyelinating diseases with etanercept, systemic Psoriasis lupus erythematosus or antiphospholipid syndrome with on September 29, 2021 by guest. Protected copyright. anti-TNF-α agents) are not considered as paradoxical. anti-TNF-α agents PAEs are uncommon and were not observed during Since an initial report in 2003,6 numerous cases have the development programme of the biological agents. been described, and two systematic literature reviews They were subsequently reported as isolated cases or case have been performed, the most recent analysing 207 series. PAEs were mainly described with anti-TNF-α cases.78Psoriasis occurring during anti-TNF-α therapy agents (first in inflammatory rheumatic diseases, and may be induced or exacerbated by biological agents then in psoriasis and CD) and more rarely with the other without identified predisposing factors. In particular, biological classes used in the treatment of RA and other co-medication such as methotrexate given for the under- conditions. This may be explained by the fact that lying disease is not a protective factor. Infections are not anti-TNF-α agents were first introduced onto the market, observed as a triggering event. Paradoxical psoriasis has and have a large number of indications. PAEs are not been observed in men and women, with no apparent organ-specific, leading to the description of a wide range age effect. Most of the patients have no previous per- of conditions, including cutaneous, intestinal, ophthal- sonal or family history of psoriasis. All the diseases mological and also vascular adverse events (table 1). treated by anti-TNF-α agents may develop paradoxical Limited data are available concerning the incidence of psoriasis, but cases seem to predominate in RA with, in PAEs. From January 2002 to September 2009, 57 cases of general, good control of the disease by the drug. new onset or aggravation of pre-existing psoriasis were Paradoxical psoriasis may occur at any time from a few
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