Inflammatory bowel disease events after exposure to interleukin 17 inhibitors secukinumab and ixekizumab: Postmarketing analysis from the RADAR (“Research on Adverse Drug events And Reports”) program

The management of patients with inflammatory bowel disease-associated spondyloarthritis: Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) and Italian Society of Rheumatology (SIR) recommendations based on a pseudo-Delphi consensus

Spondyloarthritis (SpA) is the most frequent extraintestinal manifestation in patients with inflammatory bowel diseases (IBD). When IBD and spondyloarthritis coexist, musculoskeletal and intestinal disease features should be considered when planning a therapeutic strategy. Treatment options for IBD and SpA have expanded enormously over the last few years, but randomized controlled trials with specific endpoints focused on SpA are not available in the IBD setting. To address this important clinical topic, the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) and the Italian Society of Rheumatology (SIR) jointly planned to draw updated therapeutic recommendations for IBD-associated SpA using a pseudo-Delphi method. This document presents the official recommendations of IG-IBD and SIR on the management of IBD-associated SpA in the form of 34 statements and 4 therapeutic algorithms. It is intended to be a reference guide for gastroenterologists and rheumatologists dealing with IBD-associated SpA.

Is the use of secukinumab after anti-TNF therapy greater than expected for the risk of developing inflammatory bowel disease?

OBJECTIVE

In this study, our objective was to present real-life data on the incidence of inflammatory bowel disease (IBD) among patients receiving secukinumab treatment.

METHODS

The study consisted of 209 patients who had prior exposure to anti-tumor necrosis factor (TNF) or were biologically naive. Patients with a pre-existing history of IBD were excluded from the study.

RESULTS

Of the 209 patients in the study, 176 (84.3%) had ankylosing spondylitis, while 33 (15.7%) had psoriatic arthritis. 112 (53.6%) patients had prior exposure to at least one anti-TNF treatment before initiating secukinumab. IBD developed in 10 (4.8%) of the 209 patients. The incidence of IBD among patients who initiated secukinumab as their first biologic agent was 1%. For patients who had previously received any anti-TNF treatment and subsequently transitioned to secukinumab, the incidence of IBD was 8% (p=0.018, odds ratio (OR): 8.38, 95% CI: 1.04-67.45). A mean of 3.67 months (±4.3) after anti-TNF use, whereas IBD symptoms developed in the biologically naive patient after 15 months.

CONCLUSION

Our study observed IBD incidence in 4.8% of patients using secukinumab. Patients who initiated secukinumab after previous anti-TNF treatment exhibited a significantly higher rate and risk of developing IBD. The onset of IBD occurred earlier in these patients (mean 3.67 months), whereas a single case of IBD showed a longer duration (15 months). Further studies with larger patient numbers are warranted to provide a more comprehensive understanding of our findings.

Molecularly Targeted Therapies for Inflammatory Cutaneous Granulomatous Disorders: A Review of the Evidence and Implications for Understanding Disease Pathogenesis

Inflammatory cutaneous granulomatous diseases, including granuloma annulare, cutaneous sarcoidosis, and necrobiosis lipoidica, are distinct diseases unified by the hallmark of macrophage accumulation and activation in the skin. There are currently no Food and Drug Administration-approved therapies for these conditions except prednisone and repository corticotropin injection for pulmonary sarcoidosis. Treatment of these diseases has generally been guided by low-quality evidence and may involve broadly immunomodulatory medications. Development of new treatments has in part been limited by an incomplete understanding of disease pathogenesis. Recently, there has been substantial progress in better understanding the molecular pathogenesis of these disorders, opening the door for therapeutic innovation. Likewise, reported outcomes of treatment with immunologically targeted therapies may offer insights into disease pathogenesis. In this systematic review, we summarize progress in deciphering the pathomechanisms of these disorders and discuss this in the context of emerging evidence on the use of molecularly targeted therapies in treatment of these diseases.

A Review of the Safety of Interleukin-17A Inhibitor Secukinumab

Secukinumab is an anti-interleukin (IL)-17A IgG1-κ monoclonal antibody approved for psoriasis, psoriatic arthritis, and ankylosing spondylitis. Its efficacy is well documented, but the complete safety profile of secukinumab, especially on long-term use, needs to be studied. IL-17 inhibitors increase the risk of infections, especially respiratory tract infections and candidiasis, and inflammatory bowel disease; the causal relationships are well described. However, evidence regarding the other adverse events is scarce, and causal associations between the adverse events and the biologic remain unresolved. This review aims to present a narrative perspective on the safety of secukinumab and identify some key areas where the safety of secukinumab may potentially be useful in understanding the scope of secukinumab therapy and making informed clinical decisions.

Should we be concerned about gastrointestinal-related adverse events in patients with plaque psoriasis receiving secukinumab therapy? A retrospective, real-life study

Real-world secukinumab gastrointestinal-related adverse events (GIRAE) data in psoriatic patients treated with secukinumab are lacking. A descriptive, retrospective study was performed by reviewing the medical records of patients who received secukinumab for plaque psoriasis for at least 1 year and who made a follow-up visit to the dermatology clinic of "Ospedali Riuniti Umberto I" in Ancona between December 1, 2021, and March 31, 2022. The patients' medical history and clinical data were collected at T0, before treatment, and at T1, corresponding to the last follow-up visit. Special attention was given to gastrointestinal adverse events (GIRAE). A total of 108 patients were included in the study. At baseline median PASI was 14.8 (range 2.2-27, SD 6.1), and median DLQI was 9.3 (5-16, SD 2.6). The median PASI for treated patients was 0.7 (0-3, SD 0.8; p < 0.00) 1and median DLQI was 0.3 (0-1, SD 0.5; p < 0.001). At T1 54/114 patients (50%) reached PASI100, of the other 54, 48 (88.9%) reached PASI 90 while the other six discontinued for secondary ineffectiveness. Only three patients reported a GIRAE (diarrhea), however, when screened, no IBD was found. Consistent with data in the literature, secukinumab is an effective and safe drug for the treatment of plaque psoriasis also in a real-life experience context. There should be no concern in choosing the drug for fear of possible IBDs-related GIRAE if there is no personal history or familiarity for IBDs.

Antitumor necrosis factor treatment in patients with inflammatory bowel disease does not promote psoriasis development: A meta-analysis

BACKGROUND

Recent case reports have suggested that anti-tumor necrosis factor (TNF) agents are associated with an increased risk of developing psoriasis in patients with inflammatory bowel disease (IBD).

AIMS

This meta-analysis of published studies aimed to evaluate the association between anti-TNF treatment and psoriasis in patients with IBD.

METHODS

An electronic search for original articles published before April 7, 2022, was performed using PubMed, EMBASE, and the Cochrane Library. Independent reviewers conducted the article screening and data extraction. Psoriasis development between anti-TNF-treated and anti-TNF-naïve patients was compared. Patients with ulcerative colitis and Crohn disease were compared with determine the differences in anti-TNF-induced psoriasis. Also, psoriasis development was compared according to the types of anti-TNF agents. Random-effects model meta-analyses, network meta-analysis, funnel plot asymmetry, Begg rank correlation test, and Egger regression test were performed to generate summary estimates and explore the possibility of publication bias.

RESULTS

We analyzed a total of 10,778 articles searched and 14 articles were selected to analyze. There was no significant difference in psoriasis development between anti-TNF-treated and anti-TNF-naïve patients (relative risk = 1.14; 95% confidence interval = 0.77-1.68). No differences were found for psoriasis development between anti-TNF-treated ulcerative colitis and Crohn disease patients (relative risk = 1.30; 95% confidence interval = 0.87-1.95). No significant difference was reported with respect to psoriasis development according to the types of anti-TNF agents. We found no definitive publication bias in our analyses.

CONCLUSIONS

Anti-TNF treatment did not contribute to the psoriasis development in patients with IBD. Based on our study, anti-TNF agents may be used for IBD treatment without concern for psoriasis development.

The Treatment with Interleukin 17 Inhibitors and Immune-Mediated Inflammatory Diseases

IL-17 inhibitors (IL-17i) are medicines used to treat dermatological and rheumatic diseases They belong to a class of medicines called biological disease-modifying anti-rheumatic drugs (bDMARDs). This class of drugs has had a major impact on the therapy of autoimmune diseases, being much safer and more effective than treatment with small molecules. At the same time, they have highly beneficial effects on skin and joint changes, and their efficacy has been extensively monitored and demonstrated in numerous clinical trials. More and more such drugs are still being discovered today to ensure the best possible treatment of these patients, but more frequently and relatively constantly three agents are used. Two of them (Secukinumab and Ixekizumab) inhibit IL-17A directly, and the third, Brodamulab, inhibits the IL-17A receptor. Although they are extremely effective in the treatment of these diseases, sometimes their administration has been associated with paradoxical effects, i.e., there is an exacerbation of the inflammatory process. Tough, clinical trials of IL-17i have described cases of exacerbation or even onset of inflammatory bowel disease (IBD), such as Crohn’s disease and ulcerative colitis, after administration of these drugs in patients previously diagnosed with psoriasis (PS), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). The pathophysiological mechanism of action is not well understood at present. One explanation would be that this hyperreactive inflammatory process would be triggered by Interferon 1 derived from dendritic plasma cells. Even though there are many reports in the recent literature about the role of IL17i in the onset of IBD, conclusions of studies do not converge. Some of them show an increased incidence of IBD in patients treated with IL17i, while some others affirm their safety of them. In the near future we will surely have more data emerging from ongoing meta-analyses regarding safety of use IL17i in patients who are at risk of developing IBD. Clinical and paraclinical evaluation (inflammatory intestinal markers) are carefully advised before recommending treatment with IL-17i and after initiation of treatment, and prospective surveillance by clinical and biomarkers of patients treated with IL-17i is absolutely essential to capture the onset of IBD.

New onset inflammatory bowel disease in patient treated with secukinumab: Case report and review of literature

Psoriasis is a chronic autoimmune skin disorder that can vary in severity and extent of disease. While localized disease can be managed with topical medications, widespread disease often requires systemic therapy including biologics. This medication class targets different components of the immune system and thus modulates disease activity. The biologic secukinumab is a human monoclonal antibody against interleukin-17A used for the treatment of psoriasis and psoriatic arthritis; cases of inflammatory bowel disease (IBD) have been observed in clinical trials to be associated with this medication. This review aims to provide evidence for the relationships between secukinumab treatment and the development of IBD. We have examined review articles and original research papers, published between 2010 and 2020, using the following keywords: psoriasis, psoriatic arthritis, secukinumab, IBD, Crohn's disease, ulcerative colitis, interleukin-17, IL-17, IL-17 inhibitor. Case reports have noted an association between secukinumab use and IBD and have called for IBD pre-screening in patients who will be prescribed this medication. Clinical trials concluded that secukinumab was associated with IBD, while retrospective studies have had mixed results, with most studies showing no statistical significance between secukinumab and IBD but having seen patients with history of IBD or family histories experience new-onset IBD or flare-ups. Given the utilization of secukinumab as a therapy for psoriasis and psoriatic arthritis, appropriate screening and risk stratification could help limit morbidity and mortality that can be associated with secukinumab-induced IBD.

Systematic Review and Meta-Analysis of Inflammatory Bowel Disease Adverse Events with Anti-Interleukin 17A Agents and Tumor Necrosis Factor Inhibitors in Rheumatic Disease and Skin Psoriasis

Introduction

The aim of this work is to perform a systematic review and meta-analysis of anti-tumor necrosis factor (anti-TNF) and anti-interleukin-17 (anti-IL-17) trials for spondyloarthritis, psoriatic arthritis, and psoriasis comparing rates of inflammatory bowel disease (IBD) events compared to placebo.

Methods

MEDLINE, EMBASE, and The Cochrane Library were searched for double-blind, randomized placebo-controlled anti-TNF and anti-IL-17 trials of included diseases. Inflammatory bowel disease events from the RCT period were pooled and meta-analyzed using statistical methods suitable for low-event-rate meta-analysis (Peto’s, Mantel–Haenszel, hypergeometric-normal model, and Shuster-Guo-Skyler). When observed data were insufficient, we performed an exploratory sensitivity analysis to compare methods.

Results

We identified 9551 original papers, and included 96 publications: 65 anti-TNF and 31 anti-IL-17 trials, containing 21 new and 12 flare IBD events in 28,209 participants. New IBD on anti-IL-17 occurred 0.23/100 patient-years (PY) in psoriasis, 0.61/100 PY in PsA and 1.63/100 PY in spondyloarthritis, rates similar to observational cohorts, and less commonly on anti-TNF (0/100 PY, 0/100 PY, 0.32/100 PY, respectively). No evidence of difference between groups was found, with wide CI from many pooled counts of zero, especially in placebo arms.

Conclusions

IBD events were rare, occurring at rates similar to biologic-naive groups. We could not find statistically significant differences in risk of new or recurrent IBD between treatment and control groups using selected meta-analytical methods for low event rate scenarios. Meta-analyses of this topic require more IBD events, ideally without pooling heterogeneous groups. Larger, thoroughly reported trials with systematic and detailed safety reporting are required to improve risk estimation and to make accurate inferences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00360-6.

Gastroenterological safety of IL-17 inhibitors: a systematic literature review

INTRODUCTION

Interleukin 17 is a proinflammatory cytokine considered to play a significant role in the immunopathogenesis of many chronic immune-mediated disorders. Interleukin 17 inhibitors provide an excellent treatment option for patients with psoriasis, psoriatic arthritis, or ankylosing spondylitis. However, Interleukin 17 inhibitors have been suspected of worsening or triggering new-onset inflammatory bowel disease.

AREAS COVERED

A literature search was conducted until March 2021 to investigate reporting prevalence, and characteristics of all gastroenterological adverse events in patients treated with Interleukin 17 inhibitors. One hundred and six clinical randomized trials were included, involving 40,053 patients. Inflammatory bowel disease cases were reported in 0.4% of patients exposed to Interleukin 17 inhibitors. The most frequent other gastrointestinal adverse events were diarrhea (2.5%), nausea or vomiting (0.7%), and gastroenteritis (0.2%). Sixty-one uncontrolled or retrospective studies were included, involving 16,791 patients. Sixty (0.36%) inflammatory bowel disease cases were reported, 0.6% of patients reported other gastrointestinal adverse events.

EXPERT OPINION

Interleukin 17 inhibitors are safe and effective in the treatment of psoriasis, psoriatic arthritis, and ankylosing spondylitis. Low incidence rate of developing new-onset inflammatory bowel disease or exacerbating preexisting inflammatory bowel disease with anti-IL-17 agents has been reported. Clinicians should be aware of the possibility of these concerns when considering this therapy.

Risk of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis and ankylosing spondylitis initiating interleukin 17 inhibitors: a nationwide population-based study using the French national health data system

OBJECTIVES

To investigate whether IL17-inhibitors (IL17i) initiation in real life is associated with a higher risk of inflammatory bowel disease (IBD) in patients with psoriasis (PsO), psoriatic arthritis and ankylosing spondylitis (PsA/AS).

METHODS

This nationwide cohort study involved the French national health data system database. All adults with PsO and PsA/AS who were new-users of IL17i during 2016-2019 were included. Two non-exposed PsO and PsA/AS population were included: new-users of (1) apremilast and (2) etanercept. End of follow-up was September 30, 2019. The primary end-point was an occurrence of IBD in a time-to-event analysis with propensity score-weighted Cox and Fine-Gray models.

RESULTS

A total of 16,793 IL17i new-users (mean age 48.4±13 years; 46% men); 20,556 apremilast new-users (mean age 52.5±14.6 years; 53% men); and 10,245 etanercept new-users (mean age 46.3±15 years; 44% men) were included. Previous systemic treatements were closer between IL17i and etanercept compared with apremilast. IBD occurred in 132 cases: 72 (0.43%) in IL17i new-users, 11 (0.05%) in apremilast new-users and 49 (0.48%) in etanercept new-users. Most IBD cases occurred after 6 months of exposure (82%, 55% and 76% respectively). After propensity score weighting, the risk of IBD was significantly greater with IL17i than apremilast (HR_w 3.8, 95%CI 2.1-6.8). No difference was observed between IL17i and etanercept new-users (HR_w 0.8, 95%CI 0.5-1.2).

CONCLUSION

Compared with patients initiating etanercept that displayed the same severity of the underlying disease, IL17i new-users did not present a higher risk of IBD. These results need to be confirmed in other large databases.

IL-17 Inhibitors and Inflammatory Bowel Diseases: A Postmarketing Study in Vigibase

Several gastrointestinal symptoms and chronic inflammatory bowel diseases (IBDs) have been reported after therapy with IL-17 inhibitors. To date, however, no study has shown a clear association between these drugs and IBD onset. We searched on Vigibase, the worldwide pharmacovigilance database, to investigate reporting prevalence, characteristics, and prognosis of all gastroenterological adverse events in patients treated with IL-17 inhibitors. In total, 1,129 gastrointestinal Individual Case Safety Reports (ICSRs) were identified, including 850 IBD (42.5% Crohn's disease, 31.9% ulcerative colitis, and 25.6% undifferentiated IBD) and 279 colitis (mainly undifferentiated colitis (79.2%), and microscopic colitis (10.4%)). ICSRs were associated with secukinumab (SEC, 83.6%) or ixekizumab (IXE, 16.3%), whereas only one colitis occurred with brodalumab (0.1%). Most IBD and colitis cases were detected within 6 months from therapy start in both the SEC (68.8% and 73.5%) and IXE groups (100% and 66.7%). Patients' outcomes were reported in 428 ICSRs (37.9%). Complete or ongoing recovery from symptoms was detected in about two-thirds of patients experiencing IBD (59.5%) or colitis (64.2%), whereas in the other cases, there was no recovery (33.9% and 29.5%) or there were sequelae (5.4% and 4.2%). Fatal events occurred in four patients (1.2%) in the IBD group (3 after SEC and on1e with IXE) and two SEC-treated subjects in the colitis group (2.1%). Treatment with IL-17 inhibitors is associated with a relevant number of exacerbations and new onset of IBD and colitis. Careful evaluation of gastrointestinal symptoms and the monitoring of intestinal inflammatory biomarkers should be recommended before prescribing these drugs.

Emerging Molecular Targets for the Treatment of Refractory Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown origin that has variable clinical course and can affect nearly any organ. It has a chronic course in about 25% of patients. Corticosteroids (CS) are the cornerstone of therapy but their long-term use is associated with cumulative toxicity. Commonly used CS-sparing agents include methotrexate, cyclophosphamide, azathioprine, and mycophenolate mofetil. Twenty to forty percentage of sarcoidosis patients are refractory to these therapies or develop severe adverse events. Therefore, additional and targeted CS-sparing agents are needed for chronic sarcoidosis. Macrophage activation, interferon response, and formation of the granuloma are mainly mediated by T helper-1 responses. Different pro-inflammatory cytokines such as interleukin (IL)-8, IL-12, IL-6, and tumor necrosis factor-alpha (TNF-α) have been shown to be highly expressed in sarcoidosis-affected tissues. As a result of increased production of these cytokines, Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling is constitutively active in sarcoidosis. Several studies of biological agents that target TNF-α have reported their efficacy and appear today as a second line option in refractory sarcoidosis. Some case series report a positive effect of tocilizumab an anti-IL-6 monoclonal antibody in this setting. More recently, JAK inhibition appears as a new promising strategy. This review highlights key advances on the management of chronic refractory sarcoidosis. Novel therapeutic strategies and treatment agents to manage the disease are described.

Role of the IL-23-T-bet/GATA3 Axis for the Pathogenesis of Ulcerative Colitis

Ulcerative colitis (UC) has been considered a Th2- and Th17-related disease. However, anti-IL-12/23 p40 antibody, which blocks Th1 and Th17 cell induction and maintenance, has shown efficacy in treating UC, suggesting that UC might not be a prototypical Th2 and Th17 cell-mediated autoimmune disease. To verify how the immune responses in UC patients interact with each other, we analyzed the cytokine expression and transcription factors involved in the Th1, Th2, and Th17 responses. The mucosal expression of 19 cytokines and transcription factors related to Th1, Th2, and Th17 cells, as well as Tregs, were measured by quantitative polymerase chain reaction using endoscopic biopsy specimens from inflamed colons of UC patients. A correlation analysis between the cytokines and transcription factors was conducted. The characteristic cytokine profile in UC patients has two immune response clusters: Th17-related responses and Th1-/Th2-related responses. IL-23 showed a weaker association with Th17 cell-related cytokines and transcription factor RORC and a much stronger correlation with T-bet and GATA3. In the high-IL-23-expression group, the rate of chronic continuous type was higher and the remission rate lower than in the low-IL-23-expression group. IL-23 may be a very important cytokine for evaluating the UC disease condition, as the expression of IL-23 is associated with certain clinical characteristics of UC patients. A unique association between IL-23 and T-bet/GATA3 might play a key role in the pathogenesis of UC.

Brodalumab in the treatment of chronic plaque psoriasis

INTRODUCTION

A number of highly selective biologic therapies that target specific immunological pathways of psoriasis have emerged, including molecules that target interleukin (IL)-17. IL-17 has been identified as a key effector pathogenic cytokine in psoriasis, and validated as a highly effective therapeutic target for the treatment of plaque psoriasis.

AREA COVERED

This review examines the therapeutic efficacy and safety of IL-17 inhibitors in plaque psoriasis and provides an overview of the efficacy and safety data of brodalumab compared with other IL-17 inhibitors.

EXPERT OPINION

In the real world, the treatment of psoriasis has been revolutionized by the new class of drugs belonging to IL-17 inhibitors, with secukinumab, ixekizumab, and brodalumab currently licensed and approved for the treatment of moderate-to-severe plaque psoriasis. With its distinct mechanism of action, brodalumab may offer a unique advantage over other IL-17 inhibitors due to its rapid onset of action, achievement of complete skin clearance in a high proportion of patients, and its overall favorable safety profile. Importantly, treatment with systemic biologic drugs should be established early on in the course of the disease in order to prevent comorbidities and to allow patients to achieve a stable and persistent remission.

Inflammatory bowel disease in patients with psoriasis treated with interleukin-17 inhibitors

BACKGROUND

Interleukin 17 (IL-17) inhibitors provide an excellent treatment option for patients with psoriasis and psoriatic arthritis, resulting in high levels of efficacy for skin clearance and joint improvement. Safety has also been established in clinical trials for this group of biologic agents; however, rare case reports of exacerbation or induction of inflammatory bowel disease (IBD) have been reported in the literature. No causal relationship has been established. When IL-17 inhibitors were investigated for the management of IBD, no benefit was found and worsening of disease was noted for some patients. IBD is more common in patients with psoriasis and, therefore, it remains unknown if these drugs cause de novo IBD or if the reported cases of IBD in patients on IL-17 therapy is due to the background risk in this predisposed population who may have already had an underlying or subclinical disease.

METHODS/RESULTS

A literature search was conducted for the terms 'IL-17 inhibitor,' 'ixekizumab,' 'secukinumab,' 'brodalumab' and 'inflammatory bowel disease,' 'ulcerative colitis,' and 'Crohn's disease' in PubMed and Google Scholar. Cases of new-onset or exacerbation of IBD were identified in the literature along with postmarketing pharmacovigilance data. These cases will be reviewed in this paper.

CONCLUSIONS

IL-17 inhibitors have proven efficacy for the treatment of psoriasis and psoriatic arthritis with a strong safety profile. However, rare cases of IBD onset and exacerbation in patients on IL-17 inhibitors have been reported in the literature, highlighting the need to select patients and therapeutic choices appropriately when treating this population.

Low Incidence of Inflammatory Bowel Disease Adverse Events in Adalimumab Clinical Trials Across Nine Different Diseases

Objective

Adalimumab is approved for treatment of Crohn’s disease and ulcerative colitis. Thus, we postulated that exacerbation or new‐onset of inflammatory bowel disease (IBD) would be rare events in patients treated with adalimumab for non‐IBD indications. The objective was to evaluate the incidence of IBD adverse events (AEs) across adalimumab trials.

Methods

IBD AE rates in 75 adalimumab clinical trials in rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, pediatric enthesitis‐related arthritis, uveitis, hidradenitis suppurativa, adult and pediatric psoriasis, psoriatic arthritis, nonpsoriatic arthritis peripheral spondyloarthritis (SpA), axial SpA, including nonradiographic axial SpA, and ankylosing spondylitis, were analyzed. Search terms for IBD AEs (new onset or worsening/flare) included IBD, ulcerative colitis, Crohn’s disease, and ulcerative proctitis.

Results

This analysis included 24,114 patients, representing 36,508 patient‐years of adalimumab exposure. The overall rate of IBD AEs in adalimumab‐treated patients was 0.1 (95% confidence interval [95% CI] 0.1–0.2)/100 patient‐years (41 events), ranging from no events (psoriatic arthritis, uveitis, and pediatric trials) to 0.8 (95% CI 0.2–2.2)/100 patient‐years in peripheral SpA. The rate of IBD in axial SpA was 0.6 (95% CI 0.4–1.0)/100 patient‐years. During placebo‐controlled trials, the overall IBD rate was 0.1 (95% CI 0.0–0.3)/100 patient‐years for adalimumab groups (3 events in 6,781 patients; 2,752 patient‐years of exposure) and 0.1 (95% CI 0.0–0.4)/100 patient‐years for placebo groups (1 event in 3,493 patients; 1,246 patient‐years of exposure). IBD rates in axial SpA were 0.5 (95% CI 0.1–1.4)/100 patient‐years for adalimumab and 0.6 (95% CI 0.0–3.1)/100 patient‐years for placebo.

Conclusion

The rates of IBD AEs in adalimumab clinical trials were generally low across the evaluated diseases, including axial SpA; all events occurred in adult patients.

Inflammatory Bowel Disease Onset During Secukinumab Treatment: Real Concern or Just an Expression of Dysregulated Immune Response?

BACKGROUND

Up to December 2018, eight cases of new-onset inflammatory bowel disease (IBD) were reported in the literature in patients being treated with secukinumab, an interleukin-17A antagonist prescribed for dermatologic or rheumatologic indications. The duration of secukinumab treatment ranged from a single administration to 12 months of treatment.

OBJECTIVE

The aim of our investigation was to estimate the cumulative incidence of new-onset IBD in patients treated with secukinumab for either dermatologic or rheumatologic indications.

METHODS

We carried out a survey among the dermatology and rheumatology centres in the Sicilian region (Italy) in order to identify the number of patients treated with secukinumab in the previous 24 months (November 2016-November 2018), and to understand how many of these patients eventually developed IBD after the start of secukinumab therapy.

RESULTS

Overall, four cases of IBD during secukinumab treatment were identified, with higher variability in time to onset compared with what has been previously reported, i.e. from 1 month to 5 years of secukinumab exposure. Overall, 434 patients were treated with secukinumab in Sicily between November 2016 and November 2018, and approximately 1% of these patients developed new-onset IBD.

CONCLUSIONS

Careful clinical examination of patients with respect to possible susceptibility to IBD prior to secukinumab therapy is advised.

Real-world incidence of inflammatory bowel disease among patients with other chronic inflammatory diseases treated with interleukin-17a or phosphodiesterase 4 inhibitors

Objectives: (1) To assess the real-world incidence of inflammatory bowel disease (IBD) in patients with or without other chronic inflammatory diseases (CIDs), and (2) to understand whether IBD incidence differs in CID patients receiving interleukin-17a signaling antagonists (anti-IL-17a) or phosphodiesterase 4 inhibitors (PDE4i) versus patients using a biologic not indicated for IBD or biologic-naïve patients. Methods: The MarketScan Research Databases (January 2010-July 2017) were used. A CID population was created from patients with ankylosing spondylitis, psoriatic arthritis, psoriasis or rheumatoid arthritis (RA). The CID population was stratified into different cohorts based on the baseline treatments received: (1) anti-IL-17a, (2) PDE4i, (3) biologic-naïve, and (4) non-IBD-indicated biologic (i.e. biologics not indicated for the treatment of IBD and excluding anti-IL-17a and PDE4i); a non-CID cohort was also created. The 1 year incidence rate (IR) of IBD was compared between cohorts using a logistic regression model adjusting for baseline characteristics. Results: CID cohorts included older patients than the non-CID cohort (mean age range: 48.4-54.4 versus 46.3 years). The 1 year IR of IBD was 1.41% in the anti-IL-17a cohort (N = 355), 0.68% in the PDE4i cohort (N = 2195), 0.47% in the biologic-naïve cohort (N = 424,767), 0.51% in the non-IBD-indicated biologic cohort (N = 56,317) cohort and 0.25% in the non-CID cohort (N = 1,008,436). After 1 year of follow-up, the odds of having IBD were 2.85 (p = .0213) and 1.42 (p = .1891) times higher in the anti-IL-17a and PDE4i cohorts, respectively, compared to the biologic-naïve cohort, and 2.86 (p = .0253) and 1.21 (p = .4978) times higher compared to the non-IBD-indicated biologic cohort. Similar results were observed in sensitivity analyses where patients with RA only were excluded (since anti-IL-17a and PDE4i agents are not indicated for RA). Conclusions: Anti-IL-17a treatment was associated with a nearly three-fold higher risk of IBD in CID patients. Treatment decisions for patients with CIDs should take into account the risk of developing of IBD.

Systematic review with meta-analysis: risk of new onset IBD with the use of anti-interleukin-17 agents

BACKGROUND

New onset IBD has been reported with the use of anti-IL-17 agents, but it remains unclear to what extent this is attributed to treatment or to underlying disease.

AIM

To evaluate the risk of new onset IBD with the use of anti-IL-17 agents METHODS: Electronic databases were searched for randomised controlled trials (RCT) of anti-IL-17 agents (brodalumab, ixekizumab and secukinumab). Risk of new onset IBD was compared to placebo by Mantel-Haenszel (MH) risk difference (RD). Sensitivity analyses including meta-analysis using fixed-effect model, MH and Peto odds ratio and MH risk ratio were performed due to incidence of rare adverse events. The risk of diarrhoea was also assessed due to the possibility of underdiagnosis of IBD.

RESULTS

Thirty-eight RCTs including 16 690 patients treated with anti-IL-17 agents were included. Twelve cases of new onset IBD were reported with anti-IL-17 agents in five studies, whereas no cases were reported with placebo. There was no difference in the risk of developing new onset IBD with anti-IL-17 agents compared to placebo (MH RD 0.00062, 95% CI -0.00072-0.0021, P = 0.35). Sensitivity analyses demonstrated no consistent risk with any method. There was no difference in the risk of diarrhoea (MH RD 0.0013, 95% CI -0.0014-0.0041, P = 0.34).

CONCLUSIONS

New onset IBD with the use of anti-IL-17 agents was rare. Interpretation of the results needs caution due to the presence of many zero-event studies.

Ixekizumab for the treatment of psoriasis: an update on new data since first approval

Introduction: Psoriasis is a chronic immune-mediated skin disease with a multifactorial etiology. Studies have shown that the inflammatory cytokine interleukin-17A (IL-17A) is a key mediator in the pathogenesis. Targeted biologics have changed the outcome for patients in a variety of diseases including psoriasis. Ixekizumab is a humanized monoclonal antibody directed against IL-17A and it has been approved for the treatment of moderate-to-severe plaque psoriasis, and recently also psoriatic arthritis. Areas covered: In this review, we summarize the latest clinical study results on ixekizumab. Long-term Phase III study data on efficacy and safety are now available for both plaque psoriasis and psoriatic arthritis. Additionally, new indications for ixekizumab are under investigation. Expert commentary: Overall, the efficacy and safety of ixekizumab are promising. In plaque psoriasis, the efficacy of ixekizumab was superior to etanercept and ustekinumab, while the efficacy was comparable to adalimumab in psoriatic arthritis. The safety profile has also been found very tolerable and similar to other biologics; however, vigilance regarding non-invasive Candida infections is necessary. Also, caution is advised when treating patients with concomitant inflammatory bowel disease, since ixekizumab could cause exacerbations. Long-term studies in real-life treatment settings are needed to decide the actual potential and safety of ixekizumab.

Ixekizumab: A Review of Its Use for the Management of Moderate to Severe Plaque Psoriasis

Objective: To review the efficacy, safety, and place in therapy of ixekizumab for the treatment of moderate to severe plaque psoriasis. Data Sources: PubMed (1966 to July 2018) and clinicaltrials.gov were searched using the terms ixekizumab, LY2439821, interleukin-17, and psoriasis. Study Selection and Data Extraction: Human studies published in peer-reviewed medical journals in English were used. Data Synthesis: The efficacy and safety of ixekizumab has been primarily reported by 4 phase III trials (UNCOVER-1, UNCOVER-2, UNCOVER-3, and UNCOVER-J) and multiple post hoc analyses. The average proportions of patients achieving a 75%, 90%, and 100% reduction in their Psoriasis Area and Severity Index (PASI) were 89%, 70%, and 38%, respectively, after 12 weeks of therapy. PASI75 was maintained for up to 3 years in 80.5% of participants. Ixekizumab was statistically significantly more effective than ustekinumab, with 76.5%, compared with 59%, of patients achieving PASI90 in 52 weeks. The most common adverse events include nasopharyngitis (14.1%), upper respiratory tract infections (7.9%), and injection-site reactions (6.8%), which are similar to that for other biological agents. The risk of inflammatory bowel disease may be increased with ixekizumab. Relevance to Patient Care and Clinical Practice: This review summarizes and evaluates clinical data regarding the efficacy and safety of ixekizumab and discusses relevant differences compared with other biological agents used for the management of chronic plaque psoriasis. Conclusions: Ixekizumab is a highly efficacious and well-tolerated treatment option for patients with moderate to severe plaque psoriasis.