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TNF inhibitor for immune-mediated inflammatory disease doubles the risk of paradoxical psoriasis

Presented by
Dr Nikolai Loft, Copenhagen University Hospital, Denmark
PFGC 2021
According to a Danish cohort study, patients with immune-mediated inflammatory disease treated with a tumour necrosis factor-alpha (TNFα) inhibitor had a 2-fold increased risk of new-onset psoriasis compared with those receiving conventional therapy. The risk to develop pustular psoriasis was 3 times higher compared with patients treated with a non-TNF biologic. 

Some patients with immune-mediated inflammatory disease develop paradoxical induction or worsening of psoriasis during treatment with TNFα inhibitors. As this side effect is poorly understood, a Danish cohort study explored the risk of new-onset psoriasis during treatment with a TNF inhibitor compared with the risk during treatment with non-biologic conventional treatment [1]. Dr Nikolai Loft (Copenhagen University Hospital, Denmark) and colleagues evaluated the risk of developing any type of psoriasis, non-pustular and pustular psoriasis. Data was derived from the Danish national registries, which includes all patients with inflammatory bowel disease (IBD) and/or rheumatoid arthritis (RA) who received either conventional therapy or TNF inhibitor treatment between 1995 and 2018.

The analysis included 20,910 patients treated with TNF inhibitors, of whom 108,024 patients were treated conventionally, and 4,909 patients were treated with non-TNF inhibitor biologics. During the follow-up period, 1,471 (1.4%) patients developed psoriasis. Most patients (n=1,332) suffered from non-pustular psoriasis, another 127 from psoriasis pustulosis palmoplantaris, and 12 from generalised pustular psoriasis.

The relative risk of developing non-pustular psoriasis during treatment with a TNF inhibitor was 2.12 times higher than with conventional treatment. An even higher risk of TNF inhibitor intake was associated with developing pustular psoriasis (HR 6.5). When the risk of TNF inhibitor use was compared with the risk of non-TNF biologics, TNF inhibitor use was associated with an HR of 1.85 for non-pustular and 3.11 for pustular psoriasis. Based on this data, the researchers calculated that exposure to TNF inhibitors for 241 patient-years is needed for 1 additional patient with any type of TNF inhibitor-induced psoriasis. Although non-pustular types for psoriasis constituted the most events, pustular types of psoriasis had the highest relative risk. The researchers emphasised that practitioners who treat patients with immune-mediated inflammatory disease should be aware of the risk of TNF inhibitor-induced psoriasis.

    1. Thein D, et al. Risk of anti-TNF-induced psoriasis in patients with immune‐mediated inflammatory diseases – a Danish nationwide cohort study. P27, Psoriasis from Gene to Clinic 2021, 9–11 December.


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