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Infections in psoriatic arthritis: association with treatment
Athanasios Vassilopoulos1, Konstantinos Thomas2, Dimitrios Vassilopoulos3
1Division of Internal Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
Abstract:
Serious infections (SIs) remain one of the most significant comorbidities in patients with inflammatory arthritides including psoriatic arthritis (PsA). Apart from methotrexate (MTX) and biologics such as tumor necrosis factor (TNFi), interleukin-12/23 (IL-12/23i), and IL-17 inhibitors (IL-17i), traditionally used for the treatment of PsA, recently biologics such as IL-23i and targeted synthetic agents like JAK inhibitors (JAKi) have been introduced in the daily clinical practice for the treatment of this disease. Although overall the incidence of SIs in patients with PsA treated with these agents is lower compared to patients with rheumatoid arthritis, still a number of unresolved issues regarding their safety remain. Current evidence is reassuring regarding the safety profile of conventional synthetic disease-modifying anti-rheumatic drugs, such as MTX. The increased risk for reactivation of latent infections, such as tuberculosis and hepatitis B virus (HBV) with the use of TNFi, is well described; nevertheless, it is significantly ameliorated with the appropriate screening and prophylaxis. Regarding IL-12/23i and IL-17i, there are no significant safety signals, except from an increased incidence of usually mild Candida infections with the latter class. Newer biologics such as IL-23i and targeted synthetic agents like JAKi have been recently introduced in the daily clinical practice for the treatment of this disease. While IL-23i has not been shown to increase the risk for common or opportunistic infections, a well-established association of JAKi with herpes zoster warrants the attention of rheumatologists. In this narrative review, we summarize the infectious complications of available treatment options by drug class in patients with PsA.
Insights
Serious infections are a concern in psoriatic arthritis (PsA) treatment. While some drugs are safe, others like Janus kinase inhibitors (JAKi) require careful monitoring for infections such as herpes zoster.
Area of Science:
- Rheumatology
- Immunology
- Infectious Diseases
Background:
- Serious infections (SIs) are significant comorbidities in psoriatic arthritis (PsA).
- Various disease-modifying anti-rheumatic drugs (DMARDs) are used for PsA, each with a unique safety profile regarding infections.
- Understanding these risks is crucial for managing PsA patients effectively.
Purpose of the Study:
- To review and summarize infectious complications associated with different drug classes used in PsA treatment.
- To provide an overview of the safety profiles of conventional synthetic DMARDs, biologics, and targeted synthetic agents in PsA patients.
- To highlight specific infection risks and safety considerations for clinicians.
Main Methods:
- Narrative review of available literature on infectious complications in PsA treatment.
- Categorization of infectious risks based on drug classes: conventional synthetic DMARDs, TNF inhibitors (TNFi), IL-12/23 inhibitors (IL-12/23i), IL-17 inhibitors (IL-17i), IL-23 inhibitors (IL-23i), and Janus kinase inhibitors (JAKi).
- Synthesis of evidence regarding the incidence and type of infections associated with each treatment modality.
Main Results:
- Conventional synthetic DMARDs like methotrexate (MTX) show a reassuring safety profile.
- TNFi use is associated with an increased risk of latent infections (e.g., tuberculosis, hepatitis B), manageable with screening and prophylaxis.
- IL-12/23i and IL-17i have no significant safety signals, though IL-17i may increase mild Candida infections. IL-23i does not appear to increase infection risk. JAKi are associated with herpes zoster.
Conclusions:
- Treatment of PsA involves a range of drugs with varying infection risks.
- While most treatments have manageable safety profiles, JAK inhibitors require specific attention due to the risk of herpes zoster.
- Appropriate patient screening and monitoring are essential for safe and effective PsA management.
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