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11–12 October 2017
POSTER CASE REPORTS
PSORIATIC ARTHRITIS
15. IS CERTOLIZUMAB A BETTER OPTION IN TREATMENT OF
PSORIATIC PATIENTS WITH ACTIVE JOINT AND SKIN
INVOLVEMENT?
Dr Aoife McVey, Arrow Park Hospital, Wirral
Dr Imna Fazel Rahiman and Dr Yeeho Chiu, Wirral University
Teaching Hospital NHS Trust, Wirral
Introduction: Psoriatic arthritis is an inflammatory condition affecting 5-
40% of patients with psoriasis. Common manifestations of the disease
include; sacroiliitis, dacylitis, enthesitis and uveitis. Plaque psoriasis is by
far the most common type affecting 90% of patients, but other types
include guttate and pustular psoriasis. Tumour necrosis factor alpha
(TNF-a) is a pro-inflammatory cytokine that has a key role in the patho-
physiology of psoriatic arthritis and psoriasis. Certolizumab pegol (CZP)
is a polyethylene glycolylated (PEGylated) Fab’ fragment of a hum anized
monoclonal antibody that binds and neutralizes human TNF-a. It has
recently been shown in the notable RAPID PsA trial to be effective and
safe.The RAPIDPsA trialby Measeet alwas aphase 3,double-blind rand-
omised control trial looking into the efficacy and safety of cetroluzimab
when compared to a placebo and followed up over 24 weeks. There is
no clear guidance for treatment of psoriatic patients with active skin and
joint disease. This case report and a review of the literature suggests that
Certolizumab may be better option in patients with active skin and joint
disease. In this case we present a lady with severe lifestyle limiting pustu-
lar psoriasis and psoriatic arthritis who, after multiple failed conventional
pharmacological treatments, achieved excellent symptom control using
biological agentCertoluzim abpeg ol.
Case description: We present the case of a 63-year-old lady, Mrs A, with
a background of psoriasis and palmar pustulosis affecting her feet and
hands, first diagnosed in 2002. Mrs A was admitted to hospital in January
2015 under the care of the dermatologists following an adverse reaction
of an infliximab infusion received for her psoriasis. Previous treatments
for psoriasis that failed included; cyclosporine, methotrexate,
Ustekinumab and infliximab. Importantly, she has a background of psori-
atic arthritis diagnosed in 2012 that, until her admission in 2015, only
caused only mild joint pain. Furthermore, she had various medical co-
morbidities including; Non-alcoholic fatty liver disease, pulmonary fibro-
sis, osteoarthritis andgastro-oesop hageal refluxdisease. Whilst she was
an inpatient, a rheumatology opinion was sought despite the main prob-
lem being the severe pustular psoriasis and she had active joint disease
‘she clinically had dactylitis and bilateral knee effusions. Her disease was
having debilitating effects on her quality of life and as a result she was
unable to walk due to pustules on the soles of her feet. As her disease
activity was high (DAS 6.62), she was initiated on Certolizumab pegol
200mg fortnightly and discharged from hospital after her first injection.
Follow up & Response Mrs A was followed up in April 2015 in
Rheumatology Biologics clinic and found to have had an excellent
response to treatment. After the first injection, the pustules on her hands
and feet had almost disappeared and after 2 months herjoin tdisease had
improved (DAS 2.74). At further follow up from June 2016 and January
2017, she continued to have an excellent response (DAS 1.94) and skin
remainedclear.
Discussion: Current NICE guidance recognises Certulizumab as a treat-
ment for psoriatic arthritis, but it is not currently in the group of TNF alpha
inhibitors recommended in the treatment of psoriasis. According to 2017
NICE guidance on management of psoriasis, the TNF alpha inhibitors
adalinumab, inflizimab, etanercept and Ustekinumab, can be used in the
treatment of severe psoriasis. The guidance states that alternative bio-
logical agents must only be used if; 1. Primary failure - Psoriasis does not
resolve adequately with the firstbiolo gical drug under specific NICEtech-
nology appraisal guidance 2. Secondary Failure - Psoriasis initially
responds adequately but subsequently loses its response 3. The first bio-
logical drug is not tolerated or becomes contraindicated Whether the use
of certolizumab for psoriatic arthritis with extensive skin involvement
should be considered and researched further is an important discussion
point for this case. Evidence from the RAPID PsA trial found that patients
with severe psoriatic arthritis with extensive skin involvement had a PASI
75 of64% at week 24 when treated with Certolizumab. In comparison, the
study found that Etanercept had a much lower PASI 75 response rate of
23% at week 24, highlighting it is less effective in patients with severe
psoriasis. It would therefore be interesting to research further whether
TNF alpha inhibitors have a different effect in psoriasis treatm ent when
compared to psoriatic arthritis. In this case Certolizumab was very effec-
tive in the treatment of psoriatic arthritis with severe psoriasis, compared
to Etanercept which did not have as an effective a response in this treat-
ment group. Overall, this case has demonstrated Certolizumab is an
effectivetreatmentfor psoriaticarthritis withsevere psoriasis.
Key Learning points: Certolizumab may considered in the treatment of
psoriatic arthritis with extensive skin involvement and warrants further
researchintoit’s usein thispatient group.
16. REACTIVATION OF HEPATITIS B VIRUS IN A PATIENT WITH
PSORIATIC ARTHRITIS TREATED WITH METHOTREXATE
Dr Tareg Mudawi, Whipps Cross Hospital, London
Dr Hasan Tahir and Dr Angela Pakozdi, Barts Trust, Whipps Cross
Hospital, London
Introduction: Transaminitis in psoriatic arthritis treated with disease
modifying anti-rheumatic drugs (DMARDs) is common and significant
liver damage is three times Health NHS more likely than in rheumatoid
arthritis. Commonly described risk factors include non-alcoholic fatty
liver disease, obesity, diabetes, alcohol, concomitant non-steroidal anti-
inflammatory drugs, corticosteroids and other DMARDs. Reactivation of
hepatitis B virus (HBV) in patients undergoing immunosuppressive ther-
apy is a well-recognized and potentially fatal complication, yet prevent-
able. Here we report a rare case of HBV reactivation in a patient with
psoriatic arthritis shortly after starting methotrexate treatment and to
emphasize the importance of baseline screening for chronic HBV
infection.
Case description: A 30-year old Caucasian male patient was referred
with longstanding psoriatic arthritis in May 2017. He had been treated
with sulfasalazine in the past but has been without immunosuppression
due to family planning since 2011. On examination he had active skin
psoriasis and polyarthritis. There was no other significant past medical
history, he was a non-smoker, consumed alcohol socially and did not use
any illicit drugs. He had a long-term female sexual part ner. His baseline
blood tests including liver function tests were unremarkable. He was
started on methotrexate 10 mg once weekly and folic acid 5 mg once
weekly. On his two-week monitoring blood test his liver function tests
were markedly deranged including alanine aminotransferase (ALT) of
2577 U/Land bilirubin 67umol/L. He developeda transient periodof jaun-
dice lasted for one week but did notseek medi calatte ntion and continued
with the methotrexate. He attended his follow-up rheumatology appoin t-
ment four weeks after starting the methotrexate when he was no longer
jaundiced and liver function test revealed improvement in his ALT at
119 U/L. Further liver investigations including a viral hepatitis screen
revealed reactivation of HBV. His serology showed positive HBV surface
antigen (HBsAg), low titre IgM core antibody, high titre IgG core antibody
(anti-HBc), negative e antigen and positive e antibody, with an HBV DNA
viralloadof 2.11log IU/ml.
Discussion: There is a vast amount of evidence that HBV-induced liver
inflammation is in fact mainly immune-mediated. HBV replication and
expression of viral epitopes in infected hepatocytes is followed by a pre-
dominantlyCD8þT-lymphocyteinduced acuteor chronicliver inflamma-
tion. In chronic HBV infection, spontaneous intermittent rises in ALT
levels preceded by increase in serum HBV DNA are common.
Immunosuppressive drugscan triggerthese flares,and inparticular corti-
costeroids can directly stimulate HBV replication. Furthermore, the
immunosuppressive effect on the host immune system indirectly leads to
abundantviralreplication. Inaddition, suddenwithdrawal ofimmunosup-
pressive drugs can result in an exaggerated host immune response lead-
ing to potentially life-threatening liver injury. The list of
immunosuppressive drugs associated with HBV reactivation has been
constantly expanding. The most commonly reported synthetic DMARD
associated with HBV reactivation is methotrexate. The risk of HBV reacti-
vation by methotrexate alone is therefore considered to be low but higher
with concomitant use of corticosteroids. Young male patients appear to
be at highest risk of reactivation, although the risk mostly depends on
HBsAg status. HBV screening standards and the prevention of HBV reac-
tivation have dramatically changed in the past decade. Improved recom-
mendations regarding screening for HBV infection prior to starting
immunosuppressive agents or chemotherapy have been mastered by
various gastroenterology societies. The latest one, for example, the 2017
clinical practice guideline by the European Association for the Study of
i10 11–12 October 2017 POSTER CASE REPORTS
V
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the Liver include screening all patients for HBV markers prior to starting
any immunosuppression; and in addition, HBsAg positive patients
should be offered prophylaxis with entecavir or tenofovir, whilst HBsAg-
negative anti-HBc positive subjects should receive prophylaxis if they are
at high risk of reactivation. In agreement, the 2017 BSR and BHPR guide-
line has also included recommendations on routine screening for hepati-
tisB virus(HBV)infection priorto startingDMARDs.
Key Learning points: In summary, HBV reactivation after commencing
methotrexate treatment is a potential cause of transaminitis in psoriatic
arthritis. Compelling evidence supports the routine screening for chronic
HBV infection prior to starting any immunosuppression and potent pro-
phylactictherapiesare availableto preventfatal complications.
17. CASE OF MULTIPLE INSUFFICIENCY FRACTURES IN A
PSORIATIC ARTHRITIS PATIENT
Dr Geetha Lakshmi Janakiraman, Northern Deanery, Newcastle
upon Tyne
Dr Alice Lorenzi, Freeman Hospital, Newcastle upon Tyne Hospitals
NHS Trust, Newcastle upon Tyne
Introduction: Psoriatic arthritis (PsA) is chronic inflammatory arthritis
affecting 30% of patients with skin psoriasis. We present an case of PsA
whohasencountered recurrentinsufficiency fractures.
Case description: A 59 year old female diagnosed with PsA 22 years
ago mainly presented as enthesitis of the knees and ankles. Her back-
ground includes skin psoriasis with nail changes, allergic to penicillin, ex-
smoker with COPD and Emphysema, working in a Morrisons supermar-
ket garage living with her daughter. She was initially treated with
Methotrexate(MTX) and Sulphasalazine. The later was not tolerated due
to nausea. She had similar problems with MTX but gastrointestinal side
effects responded to increase in folic acid. Her inflammatory arthritis was
poorly controlled requiring recurrent intra-articular steroids as well as
occasional intramuscular steroids for persistent ankle and knee symp-
toms. Due to persistent joint inflammation and dactylitis she was com-
menced on Adalimumab along with the MTX. Progression: She had
developed E coli 0157 diarrhoea requiring to withhold anti- TNF and MTX
to restart after infection settles. She had developed persistent foot and
ankle pain with MRI revealing insufficiency fractures at multiple sites
including distal tibial metaphysis, the navicular, heads of 4th and 5th
metatarsals, medial and intermediate cuneiforms and the calcaneum at
the point of Achilles tendon insertion. There were sclerotic areas at both
proximal tibia and femoral condyle consistent with insufficiency frac-
tures. This required moon boots, non weight bearing with crutches
impacting onher quality of life and her occupation. She had 3-4 courses of
IV Ibandronate switched to Denosumab with good reduction in bone turn
over markers. A subsequent bone scan revealed severe vertebral osteo-
porosis T score of -4.5 and -2.9 at the femoral neck. Recurrent immobili-
sation due to insufficiency fractures possibly contributing to further bone
loss. Currently she is planned to continue Adalimumab and MTX and
commence Tereparatide after the anti resorptive effective of Denosumab
hassubsided.
Discussion: Chronic psoriatic arthritis is a debilitating condition if
not well controlled can impact on quality of life. Recurrent systemic and
intra-articular steroidsthough raremay resultin steroidinduced osteopo-
rosis. Thus we present a lady with skin psoriasis and related chronic
inflammatory arthritis who had encountered either side effects with her
arthritis treatment or complications including infection, osteoporosis
resulting in multiple insufficiency fractures. Challenging question for the
experts: What is the future treatment of the osteoporosis and insuffi-
ciency fractures in our patient and how to assess it’s efficiency and
effectiveness?
Key Learning points: 1) Our patient initially presented with foot pain and
mono-arthritis unlike rheumatoid arthritis which is poly articular. Hence
was initially treated as flare though the differentials to consider would be
sepsis and as inthis case fracture. 2) Patient swith psoriasis and PsA have
increased incidence of fracture risk and osteoporosis compared to gen-
eralpopulationand rheumatoidarthritis patientsdepending onseverity of
the condition. Most of the data available for osteoporosis management
are from rheumatoid arthritis cohort rather than PsA patients. 3) There is
delay in diagnosis of osteoporotic fracture as often plain films are normal
and patient needsMRI to aid diagnosis. 4) Treatment of insufficiency frac-
tureisnon weightbearing whichin turncould result inrapid progressionof
bone mineral density. Weight bearing is extremely painful. 5)
Management of our patient included constant vigilance for any further
insufficiencyfractures.
POSTER CASE REPORTS 11–12 October 2017 i11
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