Increased Risk of TNFi-Related Psoriasis Observed in Patients with IBD, Rheumatoid Arthritis

Alexander Egeberg, MD, PhD

Despite having no prior history of psoriasis, data from a new Danish cohort revealed that some patients with immune-mediated inflammatory diseases who were treated with tumor necrosis factor-a inhibitor (TNFi) or other conventional therapies developed nonpustular types of psoriasis.

Though not as common, patients in the cohort who developed pustular types of psoriasis had the highest relative risk.

Broadly speaking, biologics have been shown to be highly effective for a number of inflammatory diseases such as psoriasis, inflammatory bowel disease (IBD), and rheumatoid arthritis. However, TNFi-associated psoriasis has developed in a myriad of patients during treatment, and studies regarding the epidemiology of these events are rare.

As such, an investigative team led by Alexander Egeberg, MD, PhD, from the University of Copenhagen, sought to determine the risk of new-onset psoriasis in patients with IBD or RA throughout TNFi treatment compared to conventional nonbiologic therapies.

The team utilized data from the Danish National Patient Registry, the Danish Register of Medicinal Product Statistics, and the National Population Registry to identify all patients in Denmark with IBS or RA from 1995-2018.

Patients with a history of any type of psoriasis prior to treatment or those who did not receive relevant pharmacotherapy after 18 years of age were excluded.

Relevant treatments were defined as either biological or nonbiological, with a distinction in the former being made between TNFi treatment and non-TNFi biological therapy.

Among the 109,085 patients enrolled in the cohort study, 108,024 received conventional therapy while 20,910 received TNFi treatment.

Cases of New-Onset Psoriasis

Throughout the follow-up period, 1471 (1.4%) patients developed a type of new-onset psoriasis. Of these patients, 1332 (91%) developed nonpustular psoriasis, and 139 (9%) developed pustular psoriasis. Among the patients who developed pustular psoriasis, 127 (91%) would go on to develop palmoplantar pustulosis, and 12 (9%) developed generalized pustulosis.

Meanwhile, the incidence rates for new-onset psoriasis per 1000 patient years were 3 for conventional therapy and 7.8 for TNFi treatment.

Regarding nonpustular andpustular psoriasis, the incidence rates for conventional therapy was 2.8 and 0.2, respectively. Incidence rates for TNFi treatment, however, was 6.5 and 1.3, respectively,

Investigators noted that 241 patient-years were required for 1 additional patient to be for any type of TNFi-associated psoriasis, while 342 patient-years were needed for nonpustular psoriasis, and 909 patient-years were needed for pustular psoriasis.

Despite an increased risk of new-onset psoriasis from TNFi treatment, investigators considered the absolute risk to be “modest” with 241 patient-years of exposure needed for 1 additional event.

“Practitioners and patients should be aware and observant of the potential for TNFi-associated psoriasis during TNFi treatment but keep in mind that the absolute risk appears to be low,” they wrote,

The study, “Absolute and Relative Risk of New-Onset Psoriasis Associated With Tumor Necrosis Factor-α Inhibitor Treatment in Patients With Immune-Mediated Inflammatory Diseases,” was published online in JAMA Dermatology.