Psoriasis: Ravaud P

Pham T, Fautrel B, Dernis E, Goupille P, Guillemin F, Le Loët X, Ravaud P, Claudepierre P, Miceli-Richard C, de Bandt M, Breban M, Maillefert JF, Masson C, Saraux A, Schaeverbeke T, Wendling D, Mariette X, Combe B, Anonymous00063. · Rheumatology Department, la Conception Teaching Hospital, 147 boulevard Baille, 13005 Marseille, France. · Joint Bone Spine. · Pubmed #18065252 No free full text.

Abstract: OBJECTIVE: To update French Society for Rheumatology guidelines regarding the use of tumor necrosis factor alpha (TNFalpha) antagonists for treating patients with ankylosing spondylitis (AS) or psoriatic arthritis (PsA). METHODS: We used the method recommended by Shekelle et al. to update the original recommendations: a limited group of experts selected the items that required updating, the relevant literature was critically appraised, and the experts developed new wording for the recommendations, which was then subjected to internal and external validation. As with the original recommendations, three topics were addressed, namely, indications of TNFalpha antagonist therapy, treatment initiation, and treatment adjustment and follow-up. RESULTS: Four criteria should be used to evaluate the indication of TNFalpha antagonist therapy. First, the patient must have a definitive diagnosis of AS or PsA. Thus, patients with AS must meet modified New York criteria or exhibit characteristic involvement of the sacroiliac joints, spine, or peripheral sites documented by radiographs or computed tomography (structural damage) or by magnetic resonance imaging (inflammation). Patients with PsA must meet validated criteria such as the Moll and Wright or CASPAR criteria. The second criterion is active disease for more than 1month, with a BASDAI >or=4 in patients with predominantly axial disease or a tender/swollen joint count >or=3, and with a physician assessment of disease activity of >or=4/10. The third criterion is failure of at least three non-steroidal anti-inflammatory drugs in patients with axial disease or of disease-modifying antirheumatic drug (DMARD) therapy (methotrexate, salazopyrine, or leflunomide) in patients with peripheral disease. Fourth, the patient must be free of contraindications to TNFalpha antagonist therapy. Four recommendations pertain to the initiation of TNFalpha antagonist therapy: a workup should be performed prior to treatment initiation; there is no evidence that one TNFalpha antagonist is more effective than the others, so decisions about drug selection should be shared with the patient and guided by available safety data and the patient's profile; there is no proof that greater effectiveness can be achieved by routinely combining a conventional DMARD; and patients should receive regular standardized follow-up. The last four recommendations deal with adjusting TNFalpha antagonist therapy: the treatment objective is a 2-point or greater improvement in the BASDAI in patients with axial disease and a 30% or greater improvement in the tender/swollen joint counts in patients with peripheral disease; there is no evidence to support the introduction of DMARD therapy in non-responders, who can be switched to another TNFalpha antagonist or, when on infliximab, given higher dosages or more closely spaced injections; patients who fail to tolerate one TNFalpha antagonist can be switched to another TNFalpha antagonist if allowed by the nature of the adverse event; and when a remission is achieved, reduction or discontinuation of concomitant anti-inflammatory therapy should be considered, followed in the event of a prolonged remission by a reduction in the dosage of the TNFalpha antagonist.

Tubach F, Salmon D, Ravaud P, Allanore Y, Goupille P, Bréban M, Pallot-Prades B, Pouplin S, Sacchi A, Chichemanian RM, Bretagne S, Emilie D, Lemann M, Lorthololary O, Mariette X, Anonymous00120. · Université Paris 7 Denis Diderot; INSERM U738; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bichat, Biostatistique et Recherche Clinique, Paris, France. · Arthritis Rheum. · Pubmed #19565495 No free full text.

Abstract: OBJECTIVE: Tuberculosis (TB) is associated with anti-tumor necrosis factor (anti-TNF) monoclonal antibody (mAb) therapy, but whether this association is drug-specific remains a concern. Our objective was to describe cases of TB associated with anti-TNF mAb therapy, identify risk factors, and estimate the incidence. METHODS: We conducted an incidence study and a case-control analysis to investigate the risk of newly diagnosed TB associated with the use of anti-TNF agents. As part of the French Research Axed on Tolerance of Biotherapies (RATIO) registry, for 3 years we collected cases of TB among French patients receiving anti-TNF mAb therapy for any indication; for each case, 2 patients treated with anti-TNF agents served as control subjects. RESULTS: We collected 69 cases of TB in patients treated for rheumatoid arthritis (n = 40), spondylarthritides (n = 18), inflammatory colitis (n = 9), psoriasis (n = 1) and Behçet's disease (n = 1) with infliximab (n = 36), adalimumab (n = 28), and etanercept (n = 5). None of the patients had received correct chemoprophylactic treatment. The sex- and age-adjusted incidence rate of TB was 116.7 per 100,000 patient-years. The standardized incidence ratio (SIR) was 12.2 (95% confidence interval [95% CI] 9.7-15.5) and was higher for therapy with infliximab and adalimumab than for therapy with etanercept (SIR 18.6 [95% CI 13.4-25.8] and SIR 29.3 [95% CI 20.3-42.4] versus SIR 1.8 [95% CI 0.7-4.3], respectively). In the case-control analysis, exposure to infliximab or adalimumab versus etanercept was an independent risk factor for TB (odds ratio [OR] 13.3 [95% CI 2.6-69.0] and OR 17.1 [95% CI 3.6-80.6], respectively). Other risk factors were age, the first year of anti-TNF mAb treatment, and being born in an endemic area. CONCLUSION: The risk of TB is higher for patients receiving anti-TNF mAb therapy than for those receiving soluble TNF receptor therapy. The increased risk with early anti-TNF treatment and the absence of correct chemoprophylactic treatment favor the reactivation of latent TB.

Tubach F, Ravaud P, Salmon-Céron D, Petitpain N, Brocq O, Grados F, Guillaume JC, Leport J, Roudaut A, Solau-Gervais E, Lemann M, Mariette X, Lortholary O, Anonymous00158. · Université Paris 7, Faculté de Medecine, Paris, France. · Clin Infect Dis. · Pubmed #17051484 No free full text.

Abstract: BACKGROUND: Patients treated with tumor necrosis factor-alpha (TNF-alpha) antagonists have an increased risk of infection, but infection due to Legionella pneumophila has rarely been described in patients receiving such therapy. METHODS: A registry involving 486 clinical departments in France was designed by a multidisciplinary group (Recherche Axée sur la Tolérance des Biothérapies [RATIO]) to collect data on opportunistic and severe infections occurring in patients treated with TNF-alpha antagonists. All cases are reported to RATIO in accordance with national health authorities and validated by infectious disease experts. The legionellosis rate among patients treated with TNF-alpha antagonists was compared with the rate in France overall. RESULTS: We report a 1-year consecutive series of 10 cases of L. pneumophila pneumonia in France in 2004, including 6 cases treated with adalimumab, 2 treated with etanercept, and 2 treated with infliximab. The median patient age was 51 years (range, 40-69 years). Eight patients were treated for rheumatoid arthritis, 1 was treated for cutaneous psoriasis, and 1 was treated for pyoderma gangrenosum. The median duration of TNF-alpha antagonist treatment at onset of infection was 38.5 weeks (range, 3-73 weeks). Eight patients were receiving concomitant treatment with corticosteroids, and 6 were receiving treatment with methotrexate. The relative risk of legionellosis when receiving treatment with a TNF-alpha antagonist, compared with the relative risk in France overall, was estimated to be between 16.5 and 21.0. We also report a second episode of confirmed legionellosis following the reintroduction of infliximab therapy. CONCLUSIONS: L. pneumophila pneumonia is a potentially severe but curable infection that might complicate anti-TNF-alpha therapy. In patients receiving anti-TNF-alpha who develop pneumonia, legionellosis should be systematically investigated, and first-line antibiotic therapy should be efficient against L. pneumophila.