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      Paradoxical Psoriasis and Worsening Spondylitis Due to Secukinumab in a Patient With Ankylosing Spondylitis: A Case Report and Literature Review

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          Abstract

          Axial spondyloarthritis (axSpA) is an autoimmune disease primarily affecting the axial skeleton, with associated extra-musculoskeletal manifestations. Treatment strategies targeting cytokines tumor necrosis factor-alpha (TNF-α) and interleukin 17 (IL-17) have proven effective. However, paradoxical reactions, including paradoxical psoriasis and arthritis, have been reported in axSpA patients receiving TNF-α inhibitors. IL-17 inhibitors have been used as an alternative treatment option, but paradoxical reactions have also been rarely observed. This case report presents a 45-year-old man with axSpA who responded to infliximab for six years before discontinuing it due to secondary failure. After the washout period of infliximab, he was started on secukinumab but developed paradoxical psoriasis and worsening of inflammatory back pain after receiving the second loading dose which necessitated replacing it with upadacitinib. Complete resolution of paradoxical psoriasis and significant improvement in his back pain after three months ensued. This case contributes to understanding the complex dynamics in treating axSpA and managing paradoxical reactions.

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          ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update

          Sofia Ramiro, Elena Nikiphorou, Alexandre Sepriano … (2022)
          Objectives To update the Assessment of SpondyloArthritis international Society (ASAS)-EULAR recommendations for the management of axial spondyloarthritis (axSpA). Methods Following the EULAR Standardised Operating Procedures, two systematic literature reviews were conducted on non-pharmacological and pharmacological treatment of axSpA. In a task force meeting, the evidence was presented, discussed, and overarching principles and recommendations were updated, followed by voting. Results Five overarching principles and 15 recommendations with a focus on personalised medicine were agreed: eight remained unchanged from the previous recommendations; three with minor edits on nomenclature; two with relevant updates (#9, 12); two newly formulated (#10, 11). The first five recommendations focus on treatment target and monitoring, non-pharmacological management and non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice pharmacological treatment. Recommendations 6–8 deal with analgesics and discourage long-term glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for pure axial involvement. Recommendation 9 describes the indication of biological DMARDs (bDMARDs, that is, tumour necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i)) and targeted synthetic DMARDs (tsDMARDs, ie, Janus kinase inhibitors) for patients who have Ankylosing Spondylitis Disease Activity Score ≥2.1 and failed ≥2 NSAIDs and also have either elevated C reactive protein, MRI inflammation of sacroiliac joints or radiographic sacroiliitis. Current practice is to start a TNFi or IL-17i. Recommendation 10 addresses extramusculoskeletal manifestations with TNF monoclonal antibodies preferred for recurrent uveitis or inflammatory bowel disease, and IL-17i for significant psoriasis. Treatment failure should prompt re-evaluation of the diagnosis and consideration of the presence of comorbidities (#11). If active axSpA is confirmed, switching to another b/tsDMARD is recommended (#12). Tapering, rather than immediate discontinuation of a bDMARD, can be considered in patients in sustained remission (#13). The last recommendations (#14, 15) deal with surgery and spinal fractures. Conclusions The 2022 ASAS-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.
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            Paradoxical reactions under TNF-α blocking agents and other biological agents given for chronic immune-mediated diseases: an analytical and comprehensive overview

            Eric Toussirot, François Aubin (2016)
            Paradoxical adverse events (PAEs) have been reported during biological treatment for chronic immune-mediated diseases. PAEs are defined as the occurrence during biological agent therapy of a pathological condition that usually responds to this class of drug. A wide range of PAEs have been reported including dermatological, intestinal and ophthalmic conditions, mainly with antitumour necrosis factor α (TNF-α) agents. True PAEs include psoriasis, Crohn's disease and hidradenitis suppurativa. Other PAEs may be qualified as borderline and include uveitis, scleritis, sarcoidosis and other granulomatous diseases (granuloma annulare, interstitial granulomatous dermatitis), vasculitis, vitiligo and alopecia areata. Proposed hypotheses to explain these PAEs include an imbalance in cytokine production, the differential immunological properties between the monoclonal antibodies and TNF-α soluble receptor, an unopposed type I interferon production and a shift towards a Th1/Th2 profile. Data from registries suggest that the risk for paradoxical psoriasis is low and non-significant. We discuss management of these PAEs, which depends on the type and severity of the adverse events, pre-existing treated conditions and the possibility of alternative therapeutic options for the underlying disease. Paradoxical adverse events are not restricted to anti-TNF-α agents and close surveillance of new available biological drugs (anti-interleukin-17/23, anti-integrin) is warranted in order to detect the occurrence of new or as yet undescribed events.
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              Paradoxical eruptions to targeted therapies in dermatology: A systematic review and analysis

              Michael J Murphy, Jeffrey M Cohen, Matthew D. Vesely … (2022)
              Antibody-based therapies that inhibit proinflammatory cytokine signaling are commonly used in dermatology. Paradoxically, these medications may induce or exacerbate inflammatory disorders.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 18 December 2023
                Publication date (Electronic, collection): December 2023
                Volume: 15
                Issue: 12
                Electronic Location Identifier: e50726
                Affiliations
                [1 ] Internal Medicine, Tawam Hospital and College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, ARE
                [2 ] Internal Medicine/Rheumatology, Tawam Hospital, Al Ain, ARE
                [3 ] Academic Affairs, Sheikh Shakhbout Medical City, Abu Dhabi, ARE
                [4 ] Rheumatology, Mediclinic, Abu Dhabi, ARE
                [5 ] Academic Affairs, Tawam Hospital, Al Ain, ARE
                [6 ] Rheumatology, Tawam Hospital, Al Ain, ARE
                [7 ] Dermatology, Tawam Hospital, Al Ain, ARE
                Author notes
                Khalid A. Alnaqbi kalnaqbi@ 123456gmail.com
                Article
                DOI: 10.7759/cureus.50726
                PMC ID: 10726796
                PubMed ID: 38111814
                SO-VID: b59e5f3c-bcec-475b-a571-56c43d7e29f9
                Copyright © Copyright © 2023, Alnaqbi et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date accepted : 17 December 2023
                Categories
                Subject: Rheumatology
                Subject: Dermatology

                Keywords: upadacitinib,jak inhibitor,paradoxical arthritis,paradoxical reaction,secukinumab,il-17 inhibitor therapy,paradoxical psoriasis,psoriasis,axial spondyloarthritis,ankylosing spondylitis
                Data availability:
                Keywords: upadacitinib, jak inhibitor, paradoxical arthritis, paradoxical reaction, secukinumab, il-17 inhibitor therapy, paradoxical psoriasis, psoriasis, axial spondyloarthritis, ankylosing spondylitis

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