T Cell Costimulation Blockade may Prevent Tumour Necrosis Factor alpha Inhibitor-Induced Palmoplantar Pustulosis

Abstract

Palmoplantar pustulosis (PPP) is a known side effect of tumour necrosis factor alpha (TNF-α) blocking agents. In this patient with HLAB27-associated spondyloarthritis, PPP started 6 months after the first exposure to Etanercept and persisted for 15 months in spite of reduced dosing for 6 months, and after discontinuation of TNF blockade and intermittent administration of topical corticosteroids for 9 months. T cell costimulation blockade using recombinant CTLA4-Ig (Abatacept) was started 4 months after stopping Etanercept for the treatment of both the refractory psoriatic skin manifestation and the joint inflammation, which relapsed after cessation of anti-TNF treatment. Only the skin manifestation responded satisfactorily to Abatacept after a delay of 5 months, but under prophylactic continuation of this treatment, it was possible to re-expose the patient to Etanercept again, thereby achieving a prompt remission of arthritis, now for more than 2 years, without a new exacerbation of PPP.

Zusammenfassung

Die palmoplantare Pustulosis (PPP) ist eine bekannte Nebenwirkung unter Therapie mit Tumor Necrosis Factor alpha (TNF-α)-Hemmern. Bei dieser Patientin mit einer HLA B27 assoziierten Spondyloarthritis trat die PPP 6 Monate nach der ersten Verabreichung von Etanercept auf und hielt für insgesamt 15 Monate an, trotz einer Dosisreduktion während 6 Monaten, anschliessender Sistierung der TNF-α-Hemmung und der intermittierenden Anwendung topischer Kortikosteroide während weiteren 9 Monaten. 4 Monate nach Beendigung der Therapie mit Etanercept wurde eine T-Zell Kostimulationshemmung begonnen unter Verwendung des rekombinanten CTLA4-Ig (Abatacept) mit der Intention, gleichzeitig die refraktären psoriatrischen Hautmanifestation und die Gelenksentzündung, welche nach der Beendigung der anti-TNF-α-Therapie wieder aufgeflammt war, zu behandeln. Nur die Hautmanifestation sprach mit 5 Monaten Verzögerung zufriedenstellend auf Abatacept an. Unter der prophylaktischen Weiterführung dieser Therapie war es nun möglich, die Patientin gegenüber Etanercept zu re-exponieren mit dem Ergebnis einer prompten und über mittlerweile mehr als 2 Jahre anhaltenden Remission der Arthritis, jetzt aber ohne erneute Exazerbation der PPP.

Key words

TNF-α inhibitor - palmoplantar pustulosis - spondyloarthritis

Schlüsselwörter

TNF-α-Hemmer - palmoplantare Pustulosis - Spondyloarthritis

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