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P586 Paradoxical psoriasis in a large cohort of IBD patients treated with anti-TNF alpha: 5 years-follow-up study

D. Pugliese*1, P.M. Ferraro2, M. Marzo1, C. Felice1, L. Celleno3, R. Landi1, G. Andrisani1, F. Pizzolante1, A. Papa1, I. De Vitis1, G. Rapaccini1, L. Guidi1, A. Armuzzi1

1Complesso Integrato Columbus, Catholic Univeristy, IBD Unit, Internal Medicine and Gastroenterology, Rome, Italy, 2Complesso Integrato Columbus, Catholic University, Nefrology, Rome, Italy, 3Complesso Integrato Columbus, Catholic Univeristy, Dermatology, Rome, Italy

Background

New onset of psoriasiform lesions is an emerging paradoxical side effect in a subgroup of patients with inflammatory bowel disease (IBD),treated with anti-TNF α. For patients with severe lesions unresponsive to topical therapy, it is necessary to withdraw from treatment with relevant impact on the management of IBD. The pathogenesis is not fully understood. Smoking seems to be a risk factor for developing these lesions. Aim of this study was to estimate the incidence of psoriasiform skin lesions in a large cohort of IBD patients treated with anti-TNF α and to analyze its clinical correlates.

Methods

A retrospective cohort study on all IBD patients who started anti-TNF α at our IBD center from January 2008 to December 2013 was performed. We recorded clinical characteristics at baseline:sex,type and duration of disease, extra-intestinal manifestations,smoking habit, type of anti-TNF α and concomitant immunosuppressive therapy. Information on time-dependent variables was updated at each clinical visit. Baseline characteristics of patients who did and did not develop psoriasis were compared with t-test, Mann-Whitney and Fisher exact test as appropriate. Proportional hazards regression models were used to estimate the association between each predictor and time to development of psoriasis. Time-dependent predictors were updated at each available time point.

Results

A total of 402 patients started anti-TNF α (both infliximab and adalimumab) between January 2008 and December 2013. There was preponderance of Crohn's disease (60%) and infliximab treated patients (60%),with a mean age at diagnosis of 40 ± 14 years.The median duration of disease was 6 years (range 0-29 years). Thirty-one percent of patients had also concomitant extra-intestinal manifestations and 21% were started on concomitant immunosuppressive therapy. Participants contributed a total of 839 person-years of follow-up, during which 42 incident cases of psoriasis were recorded, all of them confirmed by punch biopsies, with an incidence rate of 5 per 100 person-years. Comparing IBD patients with and without skin lesions, we found higher rate of smokers in the subgroup of patients who developed psoriasis (18% vs 36%, p = 0.01). Cox-regression survival analysis confirmed smoking as independent predictor of psoriasis (HR 2.37, 95%CI 1.36, 4.48, p = 0.008). Concomitant immunosuppressive therapy was inversely related to psoriasis (HR 0.33, 95% CI 0.12, 0.92, p = 0.03).

Conclusion

New onset of psoriasis is a relevant side effect of anti-TNF α therapy with an incidence rate of 5 per 100 person-years. Smoking is confirmed as the main risk factor for developing lesions. The combination therapy with anti-TNF α plus immunosuppressants was associated with a reduced risk for psoriasis.