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Paradoxical Psoriatic Arthritis with the Initiation of Brodalumab and Guselkumab

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Paradoxical Psoriatic Arthritis with the Initiation of Brodalumab and Guselkumab Henry Ford Health System Henry Ford Health System Scholarly Commons Case Reports Medical Education Research Forum 2020 5-2020 Paradoxical Psoriatic Arthritis with the Initiation of Brodalumab and Guselkumab Reem Kashlan Henry Ford Health System, [email protected] Kristin Slater Henry Ford Health System Francisca Kartono Henry Ford Health System Follow this and additional works at: https://scholarlycommons.henryford.com/merf2020caserpt Recommended Citation Kashlan, Reem; Slater, Kristin; and Kartono, Francisca, "Paradoxical Psoriatic Arthritis with the Initiation of Brodalumab and Guselkumab" (2020). Case Reports. 68. https://scholarlycommons.henryford.com/merf2020caserpt/68 This Poster is brought to you for free and open access by the Medical Education Research Forum 2020 at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Case Reports by an authorized administrator of Henry Ford Health System Scholarly Commons. Paradoxical Psoriatic Arthritis with the Initiation of Brodalumab and Guselkumab Reem Kashlan MPH, Kristin Slater MS, Francisca Kartono DO Henry Ford Health System, Detroit, Michigan Background Timeline Discussion • Paradoxical reactions have been described in the literature Paradoxical plaque psoriasis reactions have been reported with for biologics such as anti-tumor Necrosis Factor Alpha the usage of biologics, primarily with the use of anti-TNF One week later, Patient Agents, ustekinumab, secukinumab, ixekizumab1 agents. Brodalumab, a human monoclonal antibody against Patient prescribed Siliq 210 called with joint pain after starting Siliq. Severe pain interleukin-17 receptor A (IL17RA), has been proven to be mg/1.5mL subcutanous • It has been hypothesized that paradoxical reactions occur injection over the weekend in knees effective against psoriasis and psoriatic arthritis.1 A newer and shoulders. Siliq due to a cytokine imbalance resulting in an dysregulation biologic agent, guselkumab, an interleukin-23 blocker, has also discontinued of plasmacytoid dendritic cells (pDC) cells. Normally, been proven to be effective in the treatment of moderate to TNF-alpha inhibits pDCs which produce IFN-alpha. The severe psoriasis and psoriatic arthritis.2 Both of these biologics underlying mechanism involves an indirect increase of 2 have been clinically proven to be contenders for alternative IFN-alpha as a result of TNF-alpha inhibition options when a first line biologic agent may have failed, as well • Paradoxical reactions caused by these newer biologics are as in biologic naïve patients. Several weeks after unusual. Psoriatic and psoriatic arthritis reaction are more likely to occur as a new onset disease rather than a Started Tremfya 100mg/mL discontinuing Siliq the patient returned with worsening of prior disease, as seen with our patient2 We report an unusual severe worsening of arthritis in a subcutaneous injection in office resolution of his joint pain longstanding psoriasis and psoriatic arthritis patient within days and a gradual return of his • Only one case of a paradoxical reaction to brodalumab has plaque psoriasis (figure 1) of starting brodalumab, and subsequently within days of starting been published which manifested as de novo psoriatic guselkumab despite a significant clearing of plaque psoriasis. alopecia, which was effectively managed with guselkumab3 –This case outlined a sequence of events similar to our Case Report patient with rapid improvement upon initiation of Six days later, Patient was brodalumab and subsequent reaction shortly after admitted to the hospital due resolution of initial symptoms • A 47 year old white male with a long standing history of to bad flare up. He had Tremfya discontinued. fluid drained from knees Patient had improvement in psoriatic arthritis with worsening plaque psoriasis referred and had elevation of WBC. his symptoms. Conclusion to Dermatology for consideration of adding a different Was bedridden prior to hospitalization. class of biologic or alternative treatment to control his In summary, we report a previously undescribed case of a plaque psoriasis while on tofacitinib. severe paradoxical psoriatic arthritis flare in the setting of • Patient was started on brodalumab, with a return of his psoriasis improvement with the start of both brodalumab and well controlled psoriatic arthritis as a result and the Photos guselkumab injections. Although paradoxical reactions have medication was discontinued. However, patient continued been described for biologic agents in the past, this case to see improvement in his plaque psoriasis for 2 weeks. highlights a possible adverse reaction associated with the • Patient was then started on guselkumab, and the patient initiation of both brodalumab and guselkumab that one saw improvement in his plaque psoriasis until he was should be aware of. hospitalized as a result of a psoriatic arthritis flare References • During his hospitalization, he had fluid drained from both knees and an elevation of WBC. Synovial fluid culture and 1. 1. Puig L. Paradoxical Reactions: Anti-Tumor Necrosis Factor Alpha Agents, blood cultures showed no growth. He was hospitalized for Ustekinumab, Secukinumab, Ixekizumab, and Others. Curr Probl Dermatology. five days, with increasing leukocytosis with each 2017;53:49-63. doi:10.1159/000479475 2. Munera-Campos M, Ballesca F, Carrascosa JM. Paradoxical Reactions to Biologic additional day he was hospitalized. Therapy in Psoriasis: A RevieW of the Literature. Actas Dermosifiliogr. 2018;109(9):791- • Two weeks after the hospitalization the patient still 800. doi:10.1016/j.ad.2018.04.003 3. HosokaWa Y, Hamada T, Ashida H, Ikeda M. Effective treatment with guselkumab for complained of calf swelling. The patient was given psoriatic alopecia as paradoxical reaction. J Dermatol. 2019;46(8):e302-e303. prednisone and fluid was drained from both knees. doi:10.1111/1346-8138.14842 Figure 1. Return of Plaque psoriasis after stopping brodalumab ..
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