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Incidence, Clinical Characteristics, and Management of Psoriasis Induced by Anti-TNF Therapy in Patients with Inflammatory Bowel Disease: A Nationwide Cohort Study

Guerra, Iván MD; Pérez-Jeldres, Tamara; Iborra, Marisa MD, PhD; Algaba, Alicia MSc; Monfort, David MD; Calvet, Xavier MD, PhD; Chaparro, María MD, PhD; Mañosa, Miriam MD, PhD; Hinojosa, Esther; Minguez, Miguel MD, PhD; Ortiz de Zarate, Jone MD; Márquez, Lucía MD, PhD; Prieto, Vanessa MD, PhD; García-Sánchez, Valle MD, PhD; Guardiola, Jordi MD, PhD; Rodriguez, G. Esther MD; Martín-Arranz, María Dolores MD, PhD; García-Tercero, Iván MD; Sicilia, Beatriz MD, PhD; Masedo, Ángeles MD; Lorente, Rufo MD; Rivero, Montserrat MD, PhD; Fernández-Salazar, Luis MD, PhD; Gutiérrez, Ana MD; Van Domselaar, Manuel MD; López-SanRomán, Antonio MD, PhD; Ber, Yolanda MD, PhD; García-Sepulcre, Marifé MD, PhD; Ramos, Laura MD; Bermejo, Fernando PhD; Gisbert, Javier P. MD, PhDon behalf of the Spanish GETECCU group (ENEIDA project)

doi: 10.1097/MIB.0000000000000757
Original Clinical Articles

Background: Psoriasis induced by anti–tumor necrosis factor-α (TNF) therapy has been described as a paradoxical side effect.

Aim: To determine the incidence, clinical characteristics, and management of psoriasis induced by anti-TNF therapy in a large nationwide cohort of inflammatory bowel disease patients.

Methods: Patients with inflammatory bowel disease were identified from the Spanish prospectively maintained Estudio Nacional en Enfermedad Inflamatoria Intestinal sobre Determinantes genéticos y Ambientales registry of Grupo Español de Trabajo en Enfermedad de Croh y Colitis Ulcerosa. Patients who developed psoriasis by anti-TNF drugs were the cases, whereas patients treated with anti-TNFs without psoriasis were controls. Cox regression analysis was performed to identify predictive factors.

Results: Anti-TNF–induced psoriasis was reported in 125 of 7415 patients treated with anti-TNFs (1.7%; 95% CI, 1.4–2). The incidence rate of psoriasis is 0.5% (95% CI, 0.4–0.6) per patient-year. In the multivariate analysis, the female sex (HR 1.9; 95% CI, 1.3–2.9) and being a smoker/former smoker (HR 2.1; 95% CI, 1.4–3.3) were associated with an increased risk of psoriasis. The age at start of anti-TNF therapy, type of inflammatory bowel disease, Montreal Classification, and first anti-TNF drug used were not associated with the risk of psoriasis. Topical steroids were the most frequent treatment (70%), achieving clinical response in 78% of patients. Patients switching to another anti-TNF agent resulted in 60% presenting recurrence of psoriasis. In 45 patients (37%), the anti-TNF therapy had to be definitely withdrawn.

Conclusions: The incidence rate of psoriasis induced by anti-TNF therapy is higher in women and in smokers/former smokers. In most patients, skin lesions were controlled with topical steroids. More than half of patients switching to another anti-TNF agent had recurrence of psoriasis. In most patients, the anti-TNF therapy could be maintained.

Article first published online 2 March 2016.

1Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Madrid, Spain;

2Department of Gastroenterology, Hospital Clinic, Barcelona, Spain;

3Department of Gastroenterology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD);

4Department of Gastroenterology, Hospital Universitario La Fe, Valencia, Spain;

5Department of Gastroenterology, Consorci Sanitari de Terrassa, Barcelona, Spain;

6Department of Gastroenterology, Corporació Sanitaria Parc Taulí, Sabadell, Spain;

7Department of Gastroenterology, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain;

8Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain;

9Department of Gastroenterology, Hospital de Manises, Valencia, Spain;

10Department of Gastroenterology, Hospital Clínico de Valencia, Universitat de València, Valencia, Spain;

11Department of Gastroenterology, Hospital de Basurto, Bilbao, Spain;

12Department of Gastroenterology, Hospital del Mar, Barcelona, Spain;

13Department of Gastroenterology, Hospital Universitario de Salamanca, Salamanca, Spain;

14Department of Gastroenterology, Hospital Reina Sofía, IMIBIC, Universidad de Córdoba, Córdoba, Spain;

15Department of Gastroenterology, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain;

16Department of Gastroenterology, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain;

17Department of Gastroenterology, Hospital Universitario La Paz, Madrid, Spain;

18Department of Gastroenterology, Hospital Universitario Santa Lucía, Cartagena, Spain;

19Department of Gastroenterology, Hospital Universitario de Burgos, Burgos, Spain;

20Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain;

21Department of Gastroenterology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain;

22Department of Gastroenterology, Hospital Universitario Marqués de Valdecilla, Santander, Spain;

23Department of Gastroenterology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain;

24Department of Gastroenterology, Hospital General Universitario de Alicante, Alicante, Spain;

25Department of Gastroenterology, Hospital de Torrejón, Madrid, Spain;

26Department of Gastroenterology, Hospital Ramón y Cajal, Madrid, Spain;

27Department of Gastroenterology, Hospital Clínico Lozano Blesa, Zaragoza, Spain;

28Department of Gastroenterology, Hospital General Universitario de Elche, Alicante, Spain; and

29Department of Gastroenterology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.

Reprints: Iván Guerra, MD, Hospital Universitario de Fuenlabrada, Servicio de Digestivo, Camino del Molino, 2, 28942 Fuenlabrada, Madrid, Spain (e-mail:

Financial Support: Ferring laboratories have sponsored the ENEIDA registry, but they had no role in the study design, collection, analysis, and interpretation of the data or the writing of the report.

Author disclosures are available in the Acknowledgments.

Received November 27, 2015

Accepted January 20, 2016

© Crohn's & Colitis Foundation of America, Inc.
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