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De Stefano L, Pallavicini FB, Mauric E, Piccin V, Vismara EM, Montecucco C, Bugatti S. Tumor necrosis factor-α inhibitor-related immune disorders. Autoimmun Rev 2023; 22:103332. [PMID: 37062440 DOI: 10.1016/j.autrev.2023.103332] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/13/2023] [Indexed: 04/18/2023]
Abstract
Biotechnological monoclonal antibodies and receptor antagonists capable of targeting specific inflammatory actors, such as cytokines, cytokines receptors, co-stimulatory molecules or leukocyte populations, have emerged as an alternative to conventional therapies for treating systemic inflammatory diseases with immune pathogenesis. However, there is no doubt that, with a frequency that is not exceptionally high but also not negligible, immunotherapies can favour the development of systemic and organ-specific immune-mediated disorders. It has become increasingly evident that interference with a specific immune pathway may favour the activation of opposing compensatory signalling, which may exacerbate underlying subclinical disorders or cause immune-mediated diseases completely different from the underlying disease. The 'compensatory immunological switch' has emerged primarily in patients treated with tumor necrosis factor (TNF) -α inhibitors, the first biological drugs approved for treating systemic inflammatory diseases with immune pathogenesis. In this Review, we describe the clinical features and predisposing factors of the main TNF-α inhibitor-related immune disorders, organising them into subclinical serological autoimmunity, autoimmune disorders other than those for which TNF-α inhibitors are indicated, and paradoxical reactions. We also discuss the underlying pathogenetic mechanisms and precautions for use in the therapeutic management of these patients. Better understanding of the complex phenomenon of the 'compensatory immunological switch', which TNF-α inhibitors and other biological drugs might trigger, can help not only appropriately managing immune-mediated disorders, but also better interpreting the heterogeneity of the pathogenetic mechanisms underlying certain chronic inflammatory conditions that, although different from each other, are arbitrarily placed in the context of overly generic nosological entities.
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Affiliation(s)
- Ludovico De Stefano
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | | | - Eleonora Mauric
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Veronica Piccin
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Enrico Maria Vismara
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlomaurizio Montecucco
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Serena Bugatti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Cutaneous vasculitis associated with molecular tergeted therapies: systematic review of the literature. Clin Rheumatol 2023; 42:339-357. [PMID: 36369405 DOI: 10.1007/s10067-022-06406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022]
Abstract
Cutaneo us vasculitis (CV) has a broad spectrum of etiologies, and drugs are one of the main culprits. With the increasing use of targeted therapies in medicine, especially in rheumatology and oncology, the number of CV cases reported due to these drugs has increased. Therefore, the recognition and treatment of CV associated with targeted agents have become more and more important. In the literature, anti-TNFs (n = 73, 59.5%), secukinumab (n = 7, 6%), rituximab (n = 5, 4%), tocilizumab (n = 1, 0.8%), ustekinumab (n = 8, 6.5%), abatacept (n = 3, 2.4%), Janus kinase inhibitors (n = 3, 2.4%), alemtuzumab (n = 3, 2.4%), and immune checkpoint inhibitors (n = 20, 16%) have been reported as responsible agents. However, our knowledge of the pathogenetic mechanisms is fairly limited, and the standardized management is yet to be established. Furthermore, though it is uncommon, this complication may pose a safety issue. In this manuscript, we reviewed the literature on CV with or without systemic involvement related to targeted agents. We also proposed the pathogenetic mechanisms of these adverse events. Thus, we aimed to make it easier for clinicians to manage similar cases by reviewing the diagnosis and treatment processes.
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Wu A, Brown D, Wong U. A Rare Case of Leukocytoclastic Vasculitis Associated With Infliximab. GASTRO HEP ADVANCES 2022; 2:322-324. [PMID: 39132650 PMCID: PMC11307674 DOI: 10.1016/j.gastha.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/02/2022] [Indexed: 08/13/2024]
Abstract
Infliximab is a chimeric monoclonal antibody to tumor necrosis factor-α used commonly in several autoimmune conditions including Crohn's disease. We present a case of a 33-year-old man with inflammatory ileocolonic Crohn's disease who developed biopsy-proven leukocytoclastic vasculitis (LCV) exacerbated by a rechallenged dose of infliximab after years of tolerating the drug. To our knowledge, this is the first reported case of infliximab-associated LCV that occurred years after initiation of the drug. This case highlights that LCV can be a potential adverse reaction of infliximab, and health-care providers should consider a change in therapy.
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Affiliation(s)
- Angela Wu
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Danielle Brown
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Uni Wong
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Medicine, VA Maryland Health Care System, Baltimore, Maryland
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da Silva Cendon Duran C, da Paz AS, Barreto Santiago M. Vasculitis induced by biological agents used in rheumatology practice: A systematic review. Arch Rheumatol 2021; 37:300-310. [PMID: 36017201 PMCID: PMC9377167 DOI: 10.46497/archrheumatol.2022.9049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/23/2021] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
| | - Adriane Souza da Paz
- Department of Rheumatology, Serviços Especializados Em Reumatologia Da Bahia, Salvador, Brazil
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Giorgio V, Blasi E, Rigante D, Guerriero C, De Simone C, Fedele AL, Stella G, Gasbarrini A, Scaldaferri F. Anti-TNF-Related Leukocytoclastic Vasculitis in Ulcerative Colitis: A Case Report. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136711. [PMID: 34206410 PMCID: PMC8297360 DOI: 10.3390/ijerph18136711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/12/2021] [Accepted: 06/17/2021] [Indexed: 01/13/2023]
Abstract
Background: The development of drugs directed against tumor necrosis factor (TNF)-α has dramatically modified the therapeutic approach to inflammatory bowel diseases: a larger use of such drugs has also led to a major knowledge about their adverse effects, especially on skin. The aim of this report was to describe a rare steroid-dependent form of leukocytoclastic vasculitis induced by an anti-TNF-α agent in a young woman with ulcerative colitis. Case presentation: A young girl with ulcerative colitis developed a form of leukocytoclastic vasculitis induced by an anti-TNF-α agent. Recurrent palpable purpuric lesions on her legs were the main cutaneous manifestation. Skin lesions were steroid-dependent, but improved after withdrawal of the anti-TNF-α agent and second-line immunosuppressant therapy. Conclusions: The need to develop specific recommendations to guide the use of medications for managing skin reactions induced by anti-TNF-α drugs is herein emphasized.
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Affiliation(s)
- Valentina Giorgio
- Department of Life Sciences and Global Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.B.); (D.R.); (G.S.)
- Correspondence:
| | - Elisa Blasi
- Department of Life Sciences and Global Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.B.); (D.R.); (G.S.)
| | - Donato Rigante
- Department of Life Sciences and Global Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.B.); (D.R.); (G.S.)
- Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (C.D.S.); (A.G.)
| | - Cristina Guerriero
- Institute of Dermatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Clara De Simone
- Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (C.D.S.); (A.G.)
- Institute of Dermatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Anna Laura Fedele
- Institute of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Giuseppe Stella
- Department of Life Sciences and Global Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.B.); (D.R.); (G.S.)
| | - Antonio Gasbarrini
- Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (C.D.S.); (A.G.)
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Franco Scaldaferri
- Department of Internal Medicine, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
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