Treating RA With Anti-TNF Agents Is Linked With a Higher Risk of Incident Psoriasis

Kelly Davio

Biologics have become the standard of care for rheumatoid arthritis (RA) that fails to respond adequately to conventional disease-modifying antirheumatic agents (DMARDs), and overall, these agents are safe and effective. However, an association between treatment with anti–tumor necrosis factor (anti-TNF) agents and new-onset psoriasis in patients with RA has been observed.

One recent study used data from a German registry of patients treated with biologics, and it confirmed the previous observation that patients treated with anti-TNF therapies do have a higher risk of incident psoriasis compared with patients treated with DMARDs.

The registry, RABBIT, contained data for 14,525 patients with RA and no history of psoriasis, as well as 375 patients with both RA and psoriasis, up to October 2017.

In total, 117 incident psoriatic events were reported, and 5 were classified as serious. Among these events, 85 occurred in patients taking anti-TNF agents, 10 occurred in patients taking rituximab (1 patient was exposed to both rituximab and an anti-TNF agent), 6 occurred in patients treated with abatacept, 3 occurred in patients taking tocilizumab, and 14 occurred in patients taking a DMARD.

In patients who had psoriasis at baseline, 37 recurrences, 3 of them serious, were reported. In total, 20 patients were exposed to anti-TNF drugs, 6 to rituximab, 7 to abatacept, 2 to tocilizumab, and 2 to DMARDs.

The median time between enrollment in the cohort and incident psoriasis was 18 months (25%-quartile, 11 months; 75%-quartile, 46 months). In patients with a history of psoriasis, the median time from enrollment to the first recurrence was 11 months (25%-quartile, 4 months; 75%-quartile: 36 months). In total, 12% of the incident psoriatic events were palmoplantar manifestations, 16% were pustular, and 6% were palmoplantar pustulosis. Of the recurrent psoriatic events 8% were palmoplantar, 5% were pustular, and 3% were palmoplantar pustulosis.

The crude incidence rate (IR) per 1000 patient years for incident psoriasis was 3.04 for anti-TNF treatment versus 0.65 for DMARDs; the IR for the other agents studied did not differ significantly from the IR for DMARDs. Among the group with incident psoriasis, female sex (hazard ratio [HR], 1.7) and smoking (HR, 2.1) were significantly associated with psoriasis. Concomitant methotrexate was associated with a decreased risk (HR, 0.5).

The IR for recurrent psoriasis under treatment with DMARDs was 5.3 per 1000 patient-years. Cox regression showed that there was a significantly higher risk for patients with previous psoriasis to have recurrences if receiving abatacept (HR, 6.6) or rituximab (HR, 4.8).

“Physicians should be aware that there is a small but significantly increased risk of incident psoriasis” under anti-TNF treatment for RA, and that methotrexate as a comedication can lower this risk, the authors wrote. However, these results must be seen in light of the low patient numbers, and they still need further validation, the authors added.

Baganz L, Listing J, Kebow J, et al. Different risk profiles of biologic agents for new-onset psoriasis in patients with rheumatoid arthritis [published online July 11, 2019]. Semin Arthritis Rheum. doi: 10.1016/j.semarthrit.2019.07.004.
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