Etanercept monotherapy for a patient with psoriasis, psoriatic arthritis, and concomitant hepatitis C infection
2006; Elsevier BV; Volume: 54; Issue: 2 Linguagem: Inglês
10.1016/j.jaad.2005.05.043
ISSN1097-6787
AutoresCameron K. Rokhsar, Nathan Rabhan, Steven R. Cohen,
Tópico(s)Systemic Lupus Erythematosus Research
ResumoTo the Editor: A 53-year-old Russian man was under our care for severe long-standing psoriasis (37 years) and psoriatic arthritis mutilans (17 years) of the hands requiring prosthetic support (1991). The medical history included genital herpes since 1995 controlled with maintenance valacyclovir, basal cell carcinoma on the neck in 1999, and adult-onset diabetes mellitus of recent onset controlled with diet and Glucotrol (Pfizer, Morris Plains, NJ) (2.5 mg/d). A poor response to UVB and psoralen-UVA therapy led to implementation of methotrexate between 1991 and 1995 (cumulative dose: 2.6 g). However, methotrexate was discontinued when a liver biopsy revealed mild to moderate portal fibrosis. During the next 3 years, treatment with various alternative modalities proved unacceptable because of toxicity or limited efficacy, including hydroxyurea (1 g/d), cyclosporine (3.5 mg/kg/d), etretinate (10-25 mg/d), and 6-thioguanine (2-3 mg/kg/d). Methotrexate was resumed in 1996 (7.5 mg/wk) because of progressively disabling skin and joint disease. Liver biopsies performed at 6- to 12-month intervals documented liver fibrosis progression to stage II to IIIA by 1998. The gradual onset of IIIA to IIIB portal fibrosis (cumulative dose: 3.5 g) prompted discontinuation of methotrexate in 2000. A positive serology test for hepatitis C virus (HCV) was discovered at this time. Despite certain drug toxicity and HCV causing progressive liver damage, the patient elected to continue methotrexate because of profound incapacitation on withdrawal of therapy. It is noteworthy that frequent monitoring of hematologic and biochemical parameters always remained within normal limits. The patient never received therapy for HCV. The patient's desperation may be underscored by extensive psoriasiform plaques covering greater 30% of the body surface (Fig 1, A) and mutilating arthritis of the hands.Fig 1Buttocks with extensive psoriasis before (A) and 3 months after (B) etanercept therapy.View Large Image Figure ViewerDownload (PPT) In 2001, biweekly subcutaneous injections of etanercept (Enbrel, Amgen, Thousand Oaks, Calif) (25 mg) were initiated while continuing methotrexate. The patient demonstrated competency in self-administering the injections despite his physical handicap. Using polymerase chain reaction analysis, the pretreatment HCV viral load revealed greater than 1,000,000 copies/mL viral RNA (normal < 1000). Considerable improvement of psoriasis was observed after only 2 weeks of treatment. Heartened by dramatic improvement of skin and joint disease by the second month of etanercept therapy, methotrexate was gradually withdrawn. Mild to moderate reactions at the injection site were alleviated by topical steroids. No other side effects or abnormal laboratory parameters were observed. After 5 and 12 months of etanercept therapy, the pretreatment HCV viral load remained unchanged. The patient continued to be free of significant papulosquamous activity during the follow-up period (Fig 1, B). The discovery that tumor necrosis factor-alpha played an important role in the immunopathogenesis of both psoriasis and HCV1Ettehadi P. Greavers M.W. Wallach D. Aderka D. Camp R.D.R. Elevated tumor necrosis factor-alpha biologic activity in psoriatic skin lesions.Clin Exp Immunol. 1994; 96: 146-151Crossref PubMed Scopus (447) Google Scholar, 2Austin L.M. Ozawa M. Kikuchi T. Walters I.B. Kruegar G. The majority of epidermal T cells in psoriasis vulgaris lesions can produce type 1 cytokines, interferon-gamma, interleukin-2, and tumor necrosis factor-alpha, defining TC1 (cytotoxic T lymphocytes) and Th1 effector populations: a type 1 differentiation bias is also measured in circulating blood T cells in psoriatic patients.J Invest Dermatol. 1999; 113: 752-759Crossref PubMed Scopus (436) Google Scholar, 3Mussi A. Bonifati C. Carducci M. D'Agosto G. Pimpinelli F. D'Urso D. et al.Serum TNF-alpha levels correlate with disease severity and are reduced by effective therapy in plaque type psoriasis.J Biol Regul Homeost Agents. 1997; 3: 115-118Google Scholar led us to pursue a trial of etanercept for a patient with intractable generalized psoriasis, psoriatic arthritis mutilans, and HCV. Etanercept in our patient effectively controlled skin and joint disease while eliminating a concomitant dependence on methotrexate therapy. This report is consistent with a recent case study of Zein4Zein N.N. Etanercept Study Group Etanercept as an adjuvant to interferon and ribavirin in treatment-naive patients with chronic hepatitis C virus infection: a phase 2 randomized, double-blind, placebo-controlled study.J Hepatol. 2005; 42: 315-322Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar showing that etanercept is safe and effective as adjuvant therapy to interferon and ribavirin for the treatment of HCV.4Zein N.N. Etanercept Study Group Etanercept as an adjuvant to interferon and ribavirin in treatment-naive patients with chronic hepatitis C virus infection: a phase 2 randomized, double-blind, placebo-controlled study.J Hepatol. 2005; 42: 315-322Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar Moreover, our findings amplify the conclusions of one other report in which etanercept was used successfully without complications in the setting of psoriasis and HCV.5Magliocco M.A. Gottlieb A.B. Etanercept therapy for patients with psoriatic arthritis and concurrent hepatitis C virus infection: report of 3 cases.J Am Acad Dermatol. 2004; 51: 580-584Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar
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