The Use of Anti-Tumor Necrosis Factor Agents and Development of Psoriasis in Patients with Crohnʼs Disease

Abstract

Purpose: There have been case reports of psoriasis seen in patient with inflammatory bowel disease treated with anti-tumor necrosis factor (anti-TNF) agents. The pathogenesis is unclear but it was thought that anti-TNF agents inhibits INF-α production by the dermal plasmocytoid dendritic cells which leads to migration and activation of T lymphocytes into the skin and development of psoriasis. Our study aims to identify risk factors and compare the demographics in patients with Crohn's disease (CD) and psoriasis, pre and post-anti-TNF initiation. Methods: A retrospective review of electronic medical record system was performed to identify patients with CD, psoriasis and exposure to anti-TNF agents (i.e. infliximab, adalimumab and certolizumab). Data was assessed on demographics, duration of CD, CD activity (Harvey-Bradshaw index), and types of anti-TNF agents. Patients with incomplete records were excluded. Results: 6,181 patients with CD were identified from 01/1997-05/2011. Of the 29 patients with CD and psoriasis, 10 patients developed psoriasis after exposure (post-exposure group) to anti-TNF agents while 5 patients had psoriasis prior to anti-TNF exposure (pre-existing group). 14 patients were excluded due to incomplete records. The study sample consisted of Caucasians only. The median ages for post-exposure and pre-existing groups were 30 years (range 22-49 years) and 49 years (range 21-58 years), respectively. There were 7 females (70%) in the post-exposure group and 5 females (100%) in the pre-existing group. There was no statistical difference between age (p=0.10) and gender (p=0.50). The median duration from CD diagnosis to onset of psoriasis was 9 years (ranged 9 months-19 years) in post-exposure group and this was significantly longer than patients with pre-existing psoriasis of a median duration of 1.3 years (p =0.0027). Four of 10 patients (40%) in post-exposure group received their second anti-TNF agent just prior to the onset of psoriasis. This was not a significant risk factor for developing psoriasis (p=0.23). None of the study patients was exposed to certolizumab. In the post-exposure group, the median time from first exposure to anti-TNF therapy to onset of psoriasis was 3 years (range 2 months-5 years); 6 of 10 patients (60%) had active disease at the time of diagnosing psoriasis; 1 of 10 (10%) patients developed psoriasis despite discontinuation of treatment for > 3 months. Conclusion: There was no difference observed in the basic demographics of patients who developed psoriasis after anti-TNF exposure compared to those with pre-existing psoriasis. It can be concluded that the majority of patients who developed psoriasis post anti-TNF exposure had a longer duration of CD and were undergoing active anti-TNF therapy at the time. Those persons with pre-existing psoriasis were more likely to have a shorter duration of CD. Disclosure: Dr G Lichtenstein: Abbott corporation Consultant Alaven Consultant, Research Bristol-Myers Squibb Research Centocor Orthobiotech Consultant, Research Elan Consultant Ferring Consultant, Research Meda Pharmaceuticals Consultant Millenium Pharmaceuticals Consultant Pfizer Pharmaceuticals Consultant Proctor and Gamble Consultant, Research Prometheus Laboratories, Inc. Consultant, Research Salix Pharmaceuticals Consultant, Research Santarus Consultant Schering-Plough Corporation Consultant Shire Pharmaceuticals consultant, Research UCB Consultant, Research Warner Chilcotte Consultant, Research Wyeth Consultant.