Successful Treatment with Etanercept of a Patient with Psoriatic Arthritis after Adalimumab-Related Hepatotoxicity

Abstract

Inhibitors of Tumor Necrosis Factor (TNF) alpha (infliximab, etanercept, adalimumab) are nowadays widely used for the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS), not responding to conventional therapies. Anti-TNF alpha drugs have demonstrated great efficacy in slowing the disease, however, to date, concern still remains regarding acute and long-term toxicity related to TNF block. Increase in liver tests may be observed during treatment with anti-TNF agents, more often related to concomitant drugs (i.e. NSAIDS, methotrexate) or to reactivation of chronic HBV or HCV infections. However, liver damage directly induced by the drug has been described in patients treated with infliximab or adalimumab. To our knowledge, no cases of liver injury closely related to etanercept have been reported so far. We report the case of a patient with PsA who presented liver dysfunction during adalimumab, subsequently successfully treated with etanercept.

Guidelines of care for the management of psoriasis and psoriatic arthritis

“…Although there are data from rheumatoid arthritis studies suggesting that TNF-alfa inhibitors may increase total cholesterol and high-density lipoprotein cholesterol, 116 similar elevations have not been demonstrated in patients with psoriasis treated with TNF-alfa inhibitors and the significance of these findings is not known. Although significant elevations of liver enzymes occurred in 4.9% of patients during the phase III clinical trials of infliximab 117 and in a smaller percentage of patients treated with adalimumab, 118,119 the relevance of these findings in clinical practice is unclear, and the elevations are, in the majority of cases, self-correcting. Isolated case reports described the sudden development of SCC when TNF-alfa antagonists are used in patients with psoriasis and a history of significant UVB or PUVA exposure.…”

Hepatotoxicity of Agents Used in the Management of Inflammatory Bowel Disease

“…Infliximab-related hepatitis, although rare, has also been reported to resemble autoimmune hepatitis, with associated anti-nuclear and anti-smooth muscle antibodies, antibodies to double-stranded DNA and a female predominance [84] . Cross-reactivity is not necessarily seen, as successful use of etanercept has been reported after hepatitis (with marked ALT elevations) to be associated with the use of infliximab and adalimumab for various rheumatic disorders [85][86][87] . Natalizumab (Tysabri), used for severe IBD, has been recently reported as causing severe DILI [88] .…”

Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2011

“…Golimumab toxicity is associated with LFT increases (category A, C, D evidence416–421). The use of concomitant drugs and other clinical conditions confound the interpretation of this observation (FDA; category B and C evidence352 422–427). The follow-up and monitoring for increases in LFT should be governed by the patient's concomitant drugs, conditions and patient-related risk factors.…”