Active tuberculosis in psoriasis patients treated with TNF antagonists: a French nationwide retrospective study

Unmet needs in the management of psoriasis in Latin America: a systematic review

BACKGROUND

Psoriasis is a chronic, systemic inflammatory disease with a worldwide prevalence of approximately 2%. Currently, despite the difficulties faced every day by patients and physicians in low-resource countries, literature describing the exact needs of psoriasis treatment in Latin America remains scarce.

OBJECTIVE

To investigate the unmet needs in psoriasis treatment in Latin America.

METHODS

The authors conducted a systematic review following PRISMA statements in PubMed, Embase, and LILACS of studies published from January 2011 to March 2021 addressing challenges in psoriasis treatment in Latin America.

RESULTS

The search strategy identified 3,837 articles, of which 19 were included in the final analysis. Most were from Brazil (58%; n=11), all were observational, and most were cross-sectional (84%; n=16). Difficulties faced by psoriasis patients in Latin America included the high prevalence of opportunistic and endemic infections (42% of the studies addressed this matter; n=8), delay in diagnosis (5%; n=1), work productivity impairment (16%; n=3), limited access to medication/medical care (37%; n=7), poor adherence to treatment (5%; n=1) and poor adherence to guidelines (11%; n=2).

STUDY LIMITATIONS

Number and quality of studies currently available on this subject.

CONCLUSIONS

Current psoriasis guidelines do not always account for epidemiological, financial, and cultural characteristics. Most studies available are from Brazil, which might not accurately represent Latin America as a whole. In a region where neglected diseases and scarce resources remain a reality, it is imperative that dermatological training be offered to primary care providers, allowing for standardized conduct and earlier diagnosis.

Human Umbilical Cord-Derived Mesenchymal Stem Cells Alleviate Psoriasis Through TNF-α/NF-κB/MMP13 Pathway

Psoriasis is a chronic, immune-mediated disease that affects 2-3% of the global population. Recently, mesenchymal stem cells (MSCs) have been used to alleviate psoriasis. However, the therapeutic mechanisms of MSCs remain unclear. Matrix metalloproteinase-13 (MMP13), a member of the MMPs family, is the key enzyme in the cleavage of type II collagen and plays a pivotal role in extracellular matrix (ECM) remodeling. Here, it was found that Mmp13 was upregulated in the skin lesions of an imiquimod-induced mouse model, which was downregulated after intravenous infusion of human umbilical cord MSCs (hUC-MSCs). Knockdown of MMP13 inhibited the proliferation of keratinocytes and arrested the cell cycle in G1 stage. In addition, hUC-MSCs were co-cultured with THP-1 or PMA-stimulated THP-1 directly in vitro to simulate the fate of systematically infused hUC-MSCs. The level of TNF-α was decreased in the supernatant of co-cultured hUC-MSCs and THP-1 or PMA-stimulated THP-1. Moreover, it was identified that TNF-α upregulated MMP13 through the NF-κB pathway in keratinocytes. In conclusion, we propose that systematically infused hUC-MSCs exert a therapeutic effect on psoriasis through the TNF-α/NF-κB/MMP13 pathway.

Active Tuberculosis in a Patient Receiving Adalimumab for Psoriatic Arthritis and Chemoprophylaxis for Latent Tuberculosis Infection

Tumor necrosis factor (TNF) inhibitors, including adalimumab, are widely used to treat refractory psoriatic arthritis (PsA). Although isoniazid chemoprophylaxis is generally effective in preventing reactivation of latent tuberculosis infection (LTBI), prophylactic measures do not fully protect against development of active tuberculosis. We report a rare case of active tuberculosis despite chemoprophylaxis for LTBI in a patient receiving adalimumab for PsA. A 60-year-old Japanese woman who had received a diagnosis of psoriasis at age 35 years presented with arthralgia of the right hand, which she first noticed 2 months previously. Physical examination showed scattered erythematous papules and plaques with scales on her trunk, extremities, and scalp. Her right metacarpophalangeal and proximal interphalangeal joints were swollen and painful, and her right wrist and elbow were painful. PsA was diagnosed and adalimumab was initiated. Because an interferon-γ release assay (IGRA) showed a borderline result at screening, isoniazid was administered as chemoprophylaxis for LTBI. At 22 months after initiation of adalimumab, IGRA was positive and chest CT disclosed centrilobular nodules in both lungs and swelling of multiple lymph nodes. Culture of sputum at 24 months demonstrated Mycobacterium tuberculosis. Active tuberculosis was diagnosed, and treatment with a combination of isoniazid, rifampicin, ethambutol hydrochloride, and pyrazinamide was started. To ensure timely diagnosis and treatment of active tuberculosis, a tuberculosis expert should be consulted at an early stage, with regular screening and monitoring.

Disseminated Tuberculosis in a Psoriasis Patient under Adalimumab Treatment despite the Chemoprophylaxis of Latent Tuberculosis: A Case Report

Recently, biologic therapy has become a major advance in the management of moderate-to-severe psoriasis. Although the overall safety profile of biologics is favorable, primary infection or reactivation of latent tuberculosis (TB) is the major concern in the setting of tumor necrosis factor-alpha inhibitor therapy. Therefore, the treatment of latent tuberculosis infection (LTBI) before starting biologics is mandatory to prevent the reactivation of LTBI. A 27-year-old female was treated with adalimumab due to psoriasis. As latent TB was detected by the interferon-γ release assay, we started isoniazid treatment (300 mg/day) 3 weeks before starting adalimumab and maintained this for 6 months. Although the patient's psoriatic skin lesions improved, after 45 weeks of adalimumab therapy, she visited the emergency department because of fever and back pain for 2 weeks. Abdominopelvic computed tomography (CT) and chest CT revealed multiple nodular lesions on both lungs, peritoneal wall, mesentery, and spleen, along with ascites. In the ascitic fluid, adenosine deaminase was increased to 96.4 U/L, and Mycobacterium tuberculosis grew in an acid-fast bacilli culture. The patient was diagnosed with disseminated TB and treated with conventional TB medication with discontinuation of adalimumab. Five months after the completion of TB treatment, the ustekinumab, an interleukin (IL)-12/IL-23 inhibitor, was administered. Until now, her skin lesions are under excellent control without reactivation of TB for 9 months after starting ustekinumab.

Long-term safety of certolizumab pegol in plaque psoriasis: pooled analysis over 3 years from three phase III, randomized, placebo-controlled studies

Background

Certolizumab pegol (CZP) is an Fc‐free, PEGylated anti‐tumour necrosis factor biologic.

Objectives

To report 3‐year safety data from three phase III trials of CZP in adults with plaque psoriasis.

Methods

Data were pooled from CIMPASI‐1 (NCT02326298), CIMPASI‐2 (NCT02326272) and CIMPACT (NCT02346240). Included patients had moderate‐to‐severe plaque psoriasis of ≥ 6 months’ duration; had been randomized to CZP 200 mg every 2 weeks (Q2W) (400 mg at weeks 0, 2 and 4) or CZP 400 mg Q2W; and had received at least one dose of CZP with up to 144 weeks of exposure. Treatment‐emergent adverse events (TEAEs) were classified using MedDRA v18·1. Reported incidence rates (IRs) are incidence of new cases per 100 patient‐years (PY).

Results

Over 144 weeks, 995 patients received at least one dose of CZP (exposure: 2231·3 PY); 731 and 728 received at least one dose of CZP 200 mg Q2W (1211·4 PY) and/or 400 mg Q2W (1019·9 PY), respectively. The IR [95% confidence interval (CI)] of TEAEs was 144·9 (135·3–155·0) for all patients, 134·1 (123·2–145·7) for CZP 200 mg Q2W and 158·3 (145·5–171·9) for CZP 400 mg Q2W. The IR (95% CI) of serious TEAEs for all patients was 7·5 (6·4–8·8); the IRs were 6·7 (5·2–8·3) and 8·7 (6·9–10·8) for CZP 200 mg and 400 mg Q2W, respectively. Overall, 3·2% of patients reported serious infections (2·2% within each of the CZP 200 and 400 mg Q2W groups). Overall, there was one case of active tuberculosis, 16 malignancies in 14 patients and seven deaths (two considered treatment‐related). The cumulative IR of TEAEs did not increase over time.

Conclusions

No new safety signals were identified compared with previously reported data. Risk did not increase with longer or higher CZP exposure.

What is already known about this topic?

Certolizumab pegol is an Fc‐free, PEGylated, anti‐tumour necrosis factor biologic approved for adults with moderate‐to‐severe plaque psoriasis.

Safety data from phase III trials in plaque psoriasis have found the incidence of adverse events to be generally similar over 16 weeks of treatment between the evaluated certolizumab pegol doses 200 mg and 400 mg every 2 weeks and placebo.

Additionally, the safety profile was in line with the class over 48 weeks.

What does this study add?

Plaque psoriasis is a chronic disease for which patients require lifetime management; long‐term safety data are important to understand the benefits and risks of prolonged treatment.

Here, 3‐year data from a pooled analysis of three phase III trials of certolizumab pegol in plaque psoriasis are presented, representing 2231·3 patient‐years of exposure.

No new safety signals were identified and the risk of treatment‐emergent adverse events did not increase with longer or higher certolizumab pegol exposure.

Immune checkpoint inhibitors and tuberculosis: an old disease in a new context

Tuberculosis, the leading cause of infection-related death in developing regions, is a leading cause of morbidity and mortality worldwide. Screening for, and treatment of, latent Mycobacterium tuberculosis infection is routine before initiation of anti-tumour necrosis factor α (anti-TNFα) agents in the management of psoriasis, Crohn's disease, and rheumatoid arthritis. By contrast, screening for latent tuberculosis before immune checkpoint inhibitor treatment in cancer is not routine, despite the increasing number of reports of primary infection with M tuberculosis or reactivation of latent M tuberculosis infection during such treatment. We present our experience with M tuberculosis screening in 70 patients who underwent immune checkpoint inhibitor therapy for metastatic skin cancer. Based on our understanding of the interaction between M tuberculosis and the immune system, we present the argument for tuberculosis screening before immune checkpoint inhibitor therapy and its use when considering anti-TNFα treatment for severe immune-related adverse events. We call for increased vigilance during immune checkpoint inhibition until its effects on tuberculosis pathophysiology are fully ascertained.

Tuberculosis and Biologic Therapies: Anti-Tumor Necrosis Factor-α and Beyond

Biologic drugs have revolutionized the treatment of certain hematologic, autoimmune, and malignant diseases, but they may place patients at risk for reactivation or acquisition of tuberculosis. This risk is highest with the tumor necrosis factor-alpha (TNF-α) inhibitors. Amongst this class of drugs, the monoclonal antibodies (infliximab, adalimumab, golimumab) and antibody fragment (certolizumab) carry an increased risk compared to the soluble receptor fusion molecule, etanercept. Treatment of latent TB is critical to decrease the risk of reactivation. Data continues to emerge regarding tuberculosis risk associated with novel biologics targeting cytokines involved in tuberculosis control.

Efficacy and Safety of Secukinumab in Patients with Plaque Psoriasis and Latent Tuberculosis

Upon the association of biologic treatments with reactivation of latent tuberculosis infection (LTBI), screening for Mycobacterium tuberculosisinfection and anti-tuberculosis chemoprophylaxis in positive patients are required prior to biologic drug administration. Nevertheless, the risk of infection relapses associated with biologic drugs seems to be different. No cases of reactivation of LTBI have been observed in secukinumab-treated subjects, in contrast with clinical reports on the risk associated with anti-tumor necrosis factor Α-based therapy. Twelve patients with moderate to severe plaque psoriasis eligible for systemic treatment and found to have LTBI received secukinumab without previous chemoprophylaxis initiation because of clinical contraindication for 10 cases and refusal by 2 patients. None of them had tuberculosis reactivation.

Active Tuberculosis in Patients with Psoriasis Receiving Biologic Therapy: A Systematic Review

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.

Position Statement on Secukinumab in the Management of Plaque Psoriasis: The Malaysian Perspective

Psoriasis is a chronic inflammatory skin disease affecting nearly 10% of dermatologic patients in Malaysia. Treatment options include topical agents and phototherapy as well as nonbiologic and biologic systemic therapy. Mild psoriasis can often be managed with topical agents. However, managing moderate to severe psoriasis is more challenging and may require systemic treatment with nonbiologics or biologics. Despite the availability of several biologics, there are many unmet clinical needs, which may be addressed by secukinumab, an IL-17A inhibitor. This position statement is based on an expert panel discussion and is intended to provide dermatologists an overview of existing options as well as to provide a better understanding of secukinumab and how it can be integrated into current practice. During the discussion, panel members examined current approaches and the role of secukinumab in plaque psoriasis management. Panel members estimated that up to 30% of patients have moderate to severe psoriasis but only 1-2% receive biologics. Highlights from the discussion were that (i) the threshold for biologic use should be lower, in line with international guidelines; (ii) studies have shown that secukinumab has several advantages over other biologics which are greater efficacy, sustained efficacy over time, rapid onset of action, and early evidence of possible disease-modifying potential; and (iii) ideal candidates for secukinumab are all patients of moderate to severe psoriasis, including those with history of treatment failure, difficult-to-treat patterns of psoriasis (nail, scalp, and palmoplantar psoriasis), psoriatic arthritis, and comorbidities and those aiming for clear skin. Panel members recommend that secukinumab be considered first line option among biologic therapies.

Safety and tolerability of adalimumab for the treatment of psoriasis: a review summarizing 15 years of real-life experience

Biologic therapies like adalimumab are the gold standard for psoriasis treatment with efficacy and safety profiles allowing for long-term treatment. However, adalimumab cannot be used in all patients and may cause adverse drug reactions. This study reviews conditions that might limit the use of adalimumab under real-life conditions. Local injection site reactions affect 12-37% of patients but rarely require specific therapy. Dermatological adverse events (AEs) include the paradoxical psoriasis and tend to respond to adequate therapy without adalimumab discontinuation. Adalimumab increases the risk for infections; latent chronic infections like tuberculosis or hepatitis B/C impose the highest risk for serious AEs. However, administration of adalimumab may still be possible under appropriate monitoring or prophylactic therapy. Some studies indicate an increased risk of malignancies in patients with psoriasis exposed to adalimumab. Here, the causal relationship is unclear since both psoriasis and some first-line therapies increase the risk of malignancies. Depression frequently coincides with psoriasis and may respond to adalimumab as well. Cardiovascular diseases are contraindications for adalimumab, but evidence suggests that adalimumab may still be a treatment option. Overall AE rates range from 245 to 399 per 100 patient years (serious AEs: 6-23; death: 1-2). Thus, adalimumab is slightly less safe than ustekinumab and infliximab but exhibits superior effectiveness and drug survival. Adalimumab is safe for pregnant women during the first trimester, for children up to 4 years and for the elderly. Thus, in spite of several conditions that require specific attention, the favourable safety and tolerability of adalimumab for the treatment of psoriasis is confirmed.

Inhibition of IL-17A by secukinumab shows no evidence of increased Mycobacterium tuberculosis infections

Secukinumab, a fully human monoclonal antibody that selectively neutralizes interleukin-17A (IL-17A), has been shown to have significant efficacy in the treatment of moderate to severe psoriasis, psoriatic arthritis and ankylosing spondylitis. Blocking critical mediators of immunity may carry a risk of increased opportunistic infections. Here we present clinical and in vitro findings examining the effect of secukinumab on Mycobacterium tuberculosis infection. We re-assessed the effect of secukinumab on the incidence of acute tuberculosis (TB) and reactivation of latent TB infection (LTBI) in pooled safety data from five randomized, double-blind, placebo-controlled, phase 3 clinical trials in subjects with moderate to severe plaque psoriasis. No cases of TB were observed after 1 year. Importantly, in subjects with a history of pulmonary TB (but negative for interferon-γ release and receiving no anti-TB medication) or positive for latent TB (screened by interferon-γ release assay and receiving anti-TB medication), no cases of active TB were reported. Moreover, an in vitro study examined the effect of the anti-tumor necrosis factor-α (TNFα) antibody adalimumab and secukinumab on dormant M. tuberculosis H37Rv in a novel human three-dimensional microgranuloma model. Auramine-O, Nile red staining and rifampicin resistance of M. tuberculosis were measured. In vitro, anti-TNFα treatment showed increased staining for Auramine-O, decreased Nile red staining and decreased rifampicin resistance, indicative of mycobacterial reactivation. In contrast, secukinumab treatment was comparable to control indicating a lack of effect on M. tuberculosis dormancy. To date, clinical and preclinical investigations with secukinumab found no evidence of increased M. tuberculosis infections.

Factors associated with the choice of the first biologic in psoriasis: real-life analysis from the Psobioteq cohort

BACKGROUND

Decision-making is a complex process. The aim of our study was to assess factors associated with the choice of the first biological treatment in patients with moderate-to-severe psoriasis.

METHODS

Data on all patients included in the French prospective, observational, cohort, Psobioteq and initiating a first biologic prescription between July 2012 and July 2016 were analysed. Demographic information and clinical features were collected during routine clinical assessments by the dermatology team at the recruiting centres using a standardized case report form. The primary outcome was the nature of the first biologic treatment. Four groups were identified as follows: adalimumab, etanercept, ustekinumab and infliximab groups. Factors associated with the choice of the first biological agent were determined by a multinomial logistic regression model adjusted on year of inclusion.

RESULTS

The study population included the 830 biological-naïve patients who initiated a first biological agent. The mean age was 46.6 years (±SD 13.9), and 318 patients (38.3%) were female. The most commonly prescribed biologic was adalimumab: 355 (42.8%) patients, then etanercept (n = 247, 29.8%), ustekinumab (n = 194, 23.4%) and infliximab (n = 34, 4.0%). In the multinomial logistic regression analysis, patients were significantly more likely to receive adalimumab if they had a severe psoriasis as defined by baseline PASI or if they had psoriatic arthritis compared to etanercept (aOR, 0.42; 95% CI, 0.16-1.07) and ustekinumab (aOR, 0.15; 95% CI, 0.04-0.52). Patients were significantly more likely to receive ustekinumab (aOR, 2.39; 95% CI, 1.04-5.50) if they had a positive screening for latent tuberculosis compared to adalimumab. Younger patients were also more likely to receive ustekinumab. Patients with chronic obstructive pulmonary disease were more likely to be prescribed ustekinumab or etanercept compared to adalimumab. There was a trend in favour of etanercept prescription in patients with cardiovascular comorbidities, metabolic syndrome and in patients with a history of cancer.

CONCLUSION

We identified patient- and disease-related factors that have important influence on the choice of the first biological agent in clinical practice. Clinicians appear to have a holistic approach to patient characteristics when choosing a biological agent in psoriasis.