55 year old male with Psoriasis and Psoriatic arthritis was not responding to methorexate alone. He was screened for LTBI (mantoux and Quantiferon TB Gold), found negative and started on TNF blockers. Initially given Infliximab (no loading dose given) and later changed to Adalimumab after 3 doses. He had received 6 doses of Inj Adalimumab and had gone into remission when he developed cough, fever and weight loss. Evaluation revealed Dissemiated TB (Endobronchial, sputum positive and retroperitoneal LN). He was started on 4 drug ATT (HRZE), developed drug induced hepatitis 2 weeks into therapy, started on modified ATT (Streptomycin, Ethambutol and Levoflox). Hepatitis subsided, sputum AFB became negative and he improved. 6 weeks into ATT, he has developed a severe disease flare involving lower back, both knees and ankles. Uric acid 5.1 mg/dl. How best to manage his arthritis?
Very difficult case to manage. Before answering I have a few questions:
1. Was he still on MTX when started on TNF blockers? Is he still on it?
2. How long is he on ATT and how long ago was the TB and hepatitis?
3. What medications is he on right now?
Secukinumab will be an excellent option. It is fairly cheap and available in India. Ref: Secukinumab: A New Treatment Option for PsoriaticArthritis Philip Mease . Iain B. McInnes. Rheumatol Ther (2016) 3:5–29
DOI 10.1007/s40744-016-0031-5
Dear Luiza Ferreira Vieira d'Almeida,
1. Yes. Yes.
2. ATT w.e.f 4 Jan 2017. Hepatitis in 20 Jan. ATT modified thereafter. Hepatitis now resolved.
3. Methotrexate and IA steroids and modified ATT
Dear Malaviya Sir,
Thanks for the article. I came to a similar conclusion and am procuring Secukinumab.
Was wondering if I can start it immediately or do I wait till 8 weeks are over
regards
Hi Dr S,
"A dragon is dangerous only if you don't see it coming". That saying is from the unpublished book of teaching aphorism of Henri Ménard. Tb is the "dragon" during anti-TNF treatment. You and your patient knew about that risk, you are facing it and are winning. My advice is to restart the anti-TNF that sent his psoriatic arthritis into near remission or maybe switch to Enbrel. I predict that Tb will not be a problem as long as he is under active (and eventually prophylactic) anti-Tb treatment during the next 1-2 years (including 0.5-1 year after the biologic is d/c).
Secukinumab may be OK but I have no experience with it vis-à-vis the Tb risk and PsoA treatment but I have a lot with all the anti-TNFs. I presume we are all in the same boat. "Better the devil you know....."
I would make my infectious disease consultants aware of my approach and keep them on standby while we closely supervise that patient.
Best.
HM
Yes. I had a similiar scenario with a 27year old IT specialist who took Etanercept for AS for four years which transformed his life from being bedbound to fully active working abroad. He was also negative for PPD test for TB. Now he has come up with cough R sided chest x-ray opacity and +ve AFB on smear. I stopped etanercept and referred to my Pulmonology colleage who started standard 4 drug Tx for TB. He became smear negative and clinically improved from TB point of view but had a bad flare of AS after 6 weeks. My colleague allowed me to restart Etanercept after 10 weeks of ATT cover. I have yet to see him again after 2 weeks. The pulmonologist has a plan to Tx for extended pereiod i.e one year. Not sure about his plan for further prophylaxis after that. Any suggestions plz ?
Dear Dr. Shankar Subramanian,
I agree with Dr. Menard approach: you have no choice but re-start an antibody treatment (or Enbrel). You've already optimized all other treatment options.
I would consult with an infectious disease team to discuss when would be the best time to begin Ab treatment and how long to maintain anti-TB treatment/prophylaxis. I would also refer the patient to them to have another set of eyes helping minimize the risk of overlooking an important sign/symptom.
Please, do let us know how the patient responds, after all they are the reason we do what we do.
- Luiza d'Almeida
Dear all,
I would like to give a follow up on the concerned patient. The choice was really between Secukinumab Vs Etanercept. Unknown Vs Known Devil.
I finally decided to go with secukinumab. It took me a couple of weeks to procure it and the patient received the first dose on 11th March.
He was bedridden with active synovitis over knees and significant pain and stiffness over neck and lower back on 10th March. He had also developed a significant sarcopenia due to his inability to walk due to disease activity.
By 14th, he claimed improvement in his pain and started looking cheerful. He started walking independently after his second dose on 18th. He received his third dose on 25th. He is almost pain free and also contibuing his ATT. He walks to Physiotherapy department (200 m away) and has been started on both active and passive physiotherapy exercises.
His acute phase reactants have almost normalised and TB too is under control.
I shall continue to give follow up.
Thanks for all your suggestions and advice.
regards