Treatment of psoriatic arthritis with etanercept

Abstract

The secretion of proinflammatory cytokines such as tumor necrosis factor α (TNF-α) is believed to play a critical role in the pathogenesis of joint destruction in rheumatoid arthritis.1Feldman M Brennan FM Maini RM. The role of cytokines in rheumatoid arthritis.Annu Rev Immunol. 1996; 14: 397-403Crossref PubMed Scopus (2286) Google Scholar The dimeric fusion protein etanercept (Enbrel), consisting of the 75-kd TNF-α receptor linked to the Fc portion of human IgG1 has been successfully used to antagonize the persistent inflammatory stimulation due to TNF-α.2Moreland LW Baumgartner SW Schiff MH Tindall EA Fleischmann RM Weaver AL et al.Treatment of rheumatoid arthritis with a recombinant human tumor necrosis factor receptor (p75)-Fc fusion protein.N Engl J Med. 1997; 337: 141-147Crossref PubMed Scopus (1506) Google Scholar Because psoriatic arthritis in many ways resembles rheumatoid arthritis, we decided to treat a patient suffering from mutilating and extremely painful psoriatic arthritis with etanercept because of contraindications to standard therapeutic procedures such as methotrexate or cyclosporine. At presentation in our clinic in November 1999, the 50-year-old male patient was dependent on a wheelchair and a daily intake of high doses of analgesic medication, including nonsteroidal anti-inflammatory drugs and morphine. Etanercept was given at a dose of 25 mg subcutaneously twice a week, and no systemic or local side effects were observed. Four weeks after initiation of therapy an initial increase in mobility and a decrease in articular pain were noticed, leading to a reduced need for analgesic medication. The clinical improvement was accompanied by a normalization of serologic signs of inflammation, and C-reactive protein returned to normal levels during therapy. Three months after initiation of etanercept therapy, the patient was able to walk distances of up to 50 m without using the wheelchair, and the swelling and pain of the joints had decreased dramatically. Skin involvement of the disease was not significantly altered by etanercept therapy. To our knowledge, this is the first report on the use of etanercept in the treatment of psoriasis-related arthritis. According to available information etanercept has no significant organ toxicity, which makes this substance an interesting alternative for therapy in patients with contraindications to other substances commonly used for the treatment of psoriatic arthritis. Furthermore, the combination of etanercept and methotrexate has been shown to be of great efficiency in patients with rheumatoid arthritis and might be similarly effective in patients with severe psoriasis.3Weinblatt ME Kremer JM Bankhurst AD Bulpitt KJ Fleischmann RM Fox RI et al.A trial of etanercept, a recombinant tumor necrosis factor: Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate.N Engl J Med. 1999; 340: 253-259Crossref PubMed Scopus (1925) Google Scholar Taken together, the use of cytokine-antagonizing substances such as etanercept provides a promising approach in the treatment of psoriatic arthritis. Controlled randomized studies are needed to further determine the value of this substance, administered either alone or in combination with other immunosuppressive medication. Addendum: While this letter was in press, Mease et al reported a randomized trial on the successful use of etanercept therapy for psoriatic arthritis (Lancet 2000;356:385-90).