During the past decade, tumor necrosis factor-alpha (TNF-alpha) inhibitors have become a first-line therapy for moderate to severe psoriasis vulgaris (PV) and psoriatic arthritis (PsA). Because TNF-alpha blockers (eg, etanercept, adalimumab, and infliximab) are chronic therapies, safety data demonstrating that long-term use of these selectively immunosuppressive agents poses minimal risks would be reassuring.
Unfortunately, studies addressing the risks associated with the long-term use of TNF inhibitors have focused on patients with rheumatoid arthritis.
Dommasch and colleagues addressed this deficiency by performing a meta-analysis of data from 20 randomized controlled trials of 6810 adult patients with PV (n = 5427) or PsA (n = 1383). All patients had been treated with anti-TNF-alpha agents or placebo for at least 12 weeks. The meta-analysis included only randomized blinded trials that reported withdrawals and dropouts. The trials compared placebo with the following TNF-alpha antagonists: etanercept (n = 7 trials), adalimumab (n = 6), infliximab (n = 5), certolizumab (n = 1), and golimumab (n = 1).
On the basis of the meta-analysis, the authors found no statistically significant increase in overall risk for infection or malignancy in the TNF-alpha antagonist groups compared with placebo groups. Specifically:
Odds ratios for overall infection and serious infection were 1.18 (95% confidence interval [CI], 1.05-1.33) and 0.70 (95% CI, 0.40-1.21), respectively. The odds ratio for malignancy was 1.48 (95% CI, 0.71-3.09), which dropped to 1.26 (95% CI, 0.39-4.15) when nonmelanoma skin cancer (the most common malignancy) was excluded. Odds ratios were calculated over a mean follow-up period of 17.8 weeks.
Because more patients dropped out earlier from the placebo groups (ie, follow-ups were of shorter duration), the relative risks for infection and malignancy in the TNF-alpha antagonist groups may have been overestimated.
From Medscape Dermatology
TNF Antagonists and Psoriatic Disease
Graeme M. Lipper, MD
Dommasch ED, Abuabara K, Shin DB, Nguyen J, Troxel AB, Gelfand JM
J Am Acad Dermatol. 2011;64:1035-1050
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