Transcript Stop or Continue

What adverse reactions to
immunomodulators and biologics:
1) mandate discontinuation of
therapy and
2) when can medications be
continued?
Miguel Regueiro, M.D.
Professor of Medicine
Associate Chief, Education
Clinical Head and Co-Director, IBD Ctr
University of Pittsburgh Medical Ctr
1
Very little to no evidenced based
data on this subject, so…
I called some friends for help.
2
Corey Siegel – after 1 minute of laughter,
“I was asked to give this talk and turned
it down…good luck!”
3
David Rubin – “What are you
kidding me?!?!”
4
Asher Kornbluth – “I’m sorry, I can’t
hear you.”
Ed Loftus – Clearly has gone over his own
cliff…….
Jean Fred Colombel – yelled something
in French about the color blue being
sacred, the rest I couldn’t understand.
7
So, with no help from my
“friends”
8
I will give you my opinion on what to do
with IMMs/antiTNFs when an AE occurs.
We need to individualize this decision
based on severity of IBD and AE.
I look forward to further discussion
and opinion in the panel session.
9
What are the main side-effects of
6MP/Azathioprine?
Event
Frequency
Estimate
Stop therapy due to AE
11%
Allergic reactions
2%
Nausea
2%
Hepatitis
2%
Pancreatitis
3%
Serious infections
5%
non-Hodgkin’s lymphoma
Siegel CA, et al. APT 2005 (weighted average); Siegel CA, et al. CGH 2009;
Beaugerie L, et al. Lancet 2009.
0.04%-0.09% (4-9/10,000)
Adverse Events Associated with
anti-TNF Treatment
Event
Estimated
Frequency
Stop therapy due to adverse event
10%
Infusion or injection site reactions
3%-20%
Drug related lupus-like reaction
1%
Serious infections
3%
Skin
? 1-20%
Tuberculosis
0.05% (5/10,000)
Non-Hodgkin’s lymphoma (combo)
0.06% (6/10,000)
Multiple sclerosis, heart failure,
serious liver injury
Case reports only
Siegel CA.. The inflammatory bowel disease yearbook, volume 6. 2009; Infliximab package insert;
Vermeire, Gastro 2003; Cush, Ann Rheum Dis 2005; Lenercept study group, Neurology 1999; ATTACH trial 2003
Continue or Stop Rxent?
Focus on three adverse event
categories – cases from my clinic
•
•
•
•
Infections
Malignancy
Skin Complications
Thank you Drs Siegel, Rubin,
Loftus, Kornbluth, and
Colombel for your slides
12
Infections - Continue or Stop?
• 33 yo CD IFX/AZA recently relocated
from Louisville to Pittsburgh.
• For the past month he had cough,
myalgias, weight loss, and low grade
fevers.
• PPD/Quantiferon negative, but CXR
shows……..
13
CXR – Reticulonodular infiltrate
14
Bronchoscopy – what is the dx?
15
Histoplasmosis
• Urine antigen also positive for
Histoplasmosis
• Stop AZA/IFX and rx ketoconazole
• Would you restart IFX/AZA after infxn
clears?
16
Increased Risk of Opportunistic
Infections (Mayo) – AZA/antiTNF
Medication
Odds Ratio (95% CI)
P value
Any Medication
(5-ASA, AZA/6-MP,
steroids, MTX,
infliximab)
3.5 (2 - 6.1)
<0.0001*
5-ASA
1.0 (0.6 - 1.6)
0.94
Corticosteroids
3.4 (1.8 - 6.2)
<0.0001*
6-MP/azathioprine
3.1 (1.7 - 5.5)
0.0001*
Methotrexate
4.0 (0.4 - 44.1)
0.26
Infliximab
4.4 (1.2 - 17.1)
0.03
Toruner M et al, Gastroenterology 2008; 134:929-36.
Older Age Is Associated with
Opportunistic Infections
• Age at IBD diagnosis:
–Odds Ratio (per 5 years), 1.1 (1.1-1.2)
• Age at first Mayo visit:
0 – 23
–24 – 36
–37 – 49
– ≥ 50
–
1.0 (reference)
1.2 (0.5 – 2.8)
1.1 (0.5 – 2.5)
3.0 (1.2 – 7.2)
Toruner M et al, Gastroenterology 2008; 134:929-36.
The type of infections more prevelant
with anti-TNFs (granulomatous)
• Bacterial
•Tuberculosis
•Atypical mycobacterial infection
•Listeriosis
• Invasive Fungal
•Histoplasmosis
•Coccidioidomycosis
•Candidiasis
•Aspergillosis
•Pneumocystosis
Lee JH et al. Arthritis Rheum. 2002;46:2565-70
Velayos FS et al. Inflamm Bowel Dis. 2004;10:657-60
Bergstrom L et al. Arthritis Rheum. 2004;50:1959-66
20
Case - Stop or Continue?
• 27 yo male with a h/o severe Crohn’s ds
who is in remission for 4 years on 6MP
1 mg/kg.
• Over the past year he has had recurrent
“bumps” over his hands and arms.
• Not painful, but aesthetically displeasing
and affecting social life
23
What is the diagnosis?
24
Warts (likely papillomavirus)
• Despite treatment he continues to have
problems with warts.
• The 6MP is lowered but it is not until
6MP is stopped that his warts resolve.
• Can 6MP be started again in the future?
25
Thiopurines Increase the Incidence of
Certain Viral Infections - Warts
Prospective study (n=230)
NS
*
20
18
NS
16
2.0
*
1.5
Patients (%)
Infection/patient-year
14
1.0
12
10
8
6
4
0.5
2
0
AZA+
n=169
AZA–
n=61
Upper respiratory
tract infections
AZA+
n=169
AZA–
n=61
Herpes virus flare-ups
0
AZA+
AZA–
Warts at the entry
in the study
AZA+
Appearance of increased
number of warts
Seksik P et al. Aliment Pharmacol Ther 2009;29:1106-13.
NS = not significant
AZA–
Case - Continue or Stop?
• 58 yo in remission on IFX monotx for
5yrs (first 1.5 yrs on 6MP as well).
• Due for IFX infusion in 3 weeks.
• 1 wk ago developed severe pain along
back, “thought kidney stone”
• 4 days ago developed “blisters” along
back (very painful)
27
Diagnosis? Give IFX in 3 weeks?
28
Does Zoster mandate stopping?
• If pt due for antiTNF and active zoster, I
wait for blisters to “dry/scab”
• In this case she received IFX on
schedule as her lesions resolved
• Side Note: Shingles vaccine is live and
contraindicated in immunosuppressed
patients
29
Case - Continue or Stop?
• 41 yo UC in remission on Adalimumab
40mg qow and 6MP 50mg/d for 3 yrs
• 2 weeks ago worsening diarrhea – no
bleeding, but “feels like flare”
• Colonoscopy shows……..
30
What is your dx and would you
change the ADA/6MP?
31
Clostridium difficile Infection and IBD
Increasing percentage of C. diff
infections are IBD patients
Increasing number of
hospitalizations in IBD
patients with C. diff
•Classic risk factors disappearing
•Pseudomembranes usually not present
•Low threshold for checking in IBD patients with flares
•Should you stop immunosuppression? Conflicting data
Issa M, et al. Clin Gastroenterol Hepatol 2007; 5: 345-51.
Infections: Stop or Continue?
What I do….Consult with ID..then..
VIRAL
EBV, HSV, CMV,
HIV, HepB,
HepC,
HPV
BACTERIAL
Strep/Staph
Mycobact
FUNGAL
Histoplasm
Coccidio
Other
C Diff
Thiopurine
antiTNF
34
Infections: Stop or Continue?
What I do….
VIRAL
EBV, HSV, CMV,
HIV, HepB,
HepC,
HPV
Thiopurine
BACTERIAL
Strep/Staph
Mycobact
FUNGAL
Histoplasm
Coccidio
Other
C Diff
Stop if severe:
Individualize as
to who to restart
6MP/AZA
antiTNF
35
Infections: Stop or Continue?
What I do….
VIRAL
EBV, HSV, CMV,
HIV, HepB,
HepC,
HPV
Thiopurine
BACTERIAL
Strep/Staph
Mycobact
FUNGAL
Histoplasm
Coccidio
Other
C Diff
Stop
May need to stop
+ Rx virus
Individualize as
to who to restart
6MP/AZA
antiTNF
Continue
Prob ok to
continue, except
active Hep B
36
Infections: Stop or Continue?
VIRAL
EBV, HSV, CMV,
HIV, HepB,
HepC,
HPV
BACTERIAL
Strep/Staph
Mycobact
Thiopurine
Stop
Stop + Rx
May need to stop then
+ Rx virus
individualize
(if typical bact,
Individualize as
eg strep, often
to who to restart can rx through)
6MP/AZA
antiTNF
Continue
Prob ok to
continue, except
active Hep B
FUNGAL
Histoplasm
Coccidio
Other
C Diff
Stop + Rx
then
individualize
(if typical bact,
eg strep, often
can rx through)
37
Infections: Stop or Continue?
What I do….
VIRAL
EBV, HSV, CMV,
HIV, HepB,
HepC,
HPV
Thiopurine
BACTERIAL
Strep/Staph
Mycobact
Stop
Stop + Rx
May need to stop then
+ Rx virus
individualize
FUNGAL
Histoplasm
Coccidio
Other
C Diff
Stop + Rx then
Restart when
cleared
Individualize as
to who to restart
6MP/AZA
antiTNF
Continue
Prob ok to
continue, except
active Hep B
Stop + Rx
then
individualize
Stop + Rx then
Restart when
cleared
38
Infections: Stop or Continue?
What I do….
VIRAL
EBV, HSV, CMV,
HIV, HepB,
HepC,
HPV
Thiopurine
BACTERIAL
Strep/Staph
Mycobact
Stop
Stop + Rx
May need to stop then
+ Rx virus
individualize
FUNGAL
Histoplasm
Coccidio
Other
C Diff
Stop + Rx then
Restart when
cleared
Probably
continue
Stop + Rx then
Restart when
cleared
Probably
continue
Individualize as
to who to restart
6MP/AZA
antiTNF
Continue
Prob ok to
continue, except
active Hep B
Stop + Rx
then
individualize
39
Malignancy
-Lymphoma
- Solid Tumors
40
Case – Stop or Continue?
• 39 yo male CD in remission on 6MP/IFX
for 8 yrs.
• Now with weight loss, sweats, and low
grade fevers
41
Large periaortic LNs involving left
renal cortex – diagnosis?
42
Non-Hodgkin’s Lymphoma
•
•
•
•
What do you do now?
Stop IFX and continue 6MP?
Stop 6MP and continue IFX?
Stop both?
43
In contrast: Hepatosplenic T cell
lymphoma – enlarged spleen, otherwise
nonspecific
44
AZA/6-MP are probably related to
Lymphoma (Meta-analysis): SIR 4.06
Author
Observed
Expected
Connell
0
0.52
Kinlen
2
0.24
Farrell
2
0.05
Lewis
1
0.64
Fraser
3
0.65
Korelitz
3
0.61
Total
11
2.71
SIR = 4.06, 95% CI 2.01 – 7.28
Kandiel A et al. Gut. 2005:54:1121-25
CESAME – 6MP/AZA Only
Lymphoma: HR 5.3
At cohort
entry
N
#
HR (95% CI)
Lymphomas
Never
exposed to
thiopurines
10,810
6
Reference
On therapy
with
thiopurines
5,867
16
5.3
(2.0 – 13.9)
Previously
discontinued
thiopurines
2,809
2
1.0
(0.2 – 5.1)
Beaugerie L. Lancet 2009 DOI:10.1016/S0140-6736(09)61302-7
Risk of NH Lymphoma with anti-TNF + IM
treatment for Crohn’s Disease: A Meta-Analysis
•
•
•
•
8905 patients representing 20,602 pt-years of exposure
13 Non-Hodgkin’s lymphomas  6.1 per 10,000 pt-years
Mean age 52, 62% male
10/13 exposed to IM* (really a study of combo Rx)
NHL rate
per 10,000
SIR
95% CI
SEER all ages
1.9
-
-
IM alone
3.6
-
-
Anti-TNF + IM vs SEER
6.1
3.23
1.5-6.9
Anti-TNF+ IM vs IM alone
6.1
1.7
0.5-7.1
Siegel et al, CGH 2009;7:874.
*not reported in 2
CESAME – Combo 6MP/AZA and
antiTNF: SIR = 10.2
Therapy
Patients
# Lymph
SIR
95% CI
Never thiopurine
or TNF
22,706
6
1.5
0.5 – 3.2
Current
thiopurine
without TNF
14,729
13
6.5
3.5 – 11.2
Current
thiopurine + TNF
1,929
2
10.2
1.2 – 36.9
Beaugerie L. Lancet 2009 DOI:10.1016/S0140-6736(09)61302-7
Case Continue or Stop?
• 58 yo female with severe UC who has
been on IFX/6MP (50mg/d) for past 1yr
• Just diagnosed with intraductal breast
CA (T1N0MX)
• Strong FHx breast CA, pt opts for
bilateral mastectomy
• After consultation with oncology, the
decision is to cont meds
49
No clear association between
thiopurines/antiTNFs and solid tumors
in IBD
Study
Types of
cancer
Number of
patients
Statistically
significant
lung, breast
1955
NO
Fraser 2002
breast,
bronchial, renal
6262
NO
Connell 1994
gastric, lung,
breast, cervical
755
NO
Armstrong 2010
…..but DO seem associated with increased
risk of skin cancers and lymphoma
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
LYMPHOMA
HSTC Lymphoma
SOLID TUMORS
Thiopurine
antiTNF
51
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
LYMPHOMA
Thiopurine
Continue or start:
Previously Rx’d and
inactive >1 yr
antiTNF
Continue or start:
Previously Rx’d and
inactive >1 yr
HSTC Lymphoma
SOLID TUMORS
52
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
LYMPHOMA
Thiopurine
HSTC Lymphoma
SOLID TUMORS
Continue or start:
Previously Rx’d and
inactive >1 yr
Stop:
New Lymphoma,
esp EBV on 6MP
antiTNF
Continue or start:
Previously Rx’d and
inactive >1 yr
Stop:
New Lymphoma
?Restart
53
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
Thiopurine
LYMPHOMA
HSTC Lymphoma
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
Stop:
New Lymphoma,
esp EBV on 6MP
antiTNF
SOLID TUMORS
-Has been a fatal
lymphoma.
-Even if eradicated,
avoid future 6MP
Continue or start:
Previously Rx’d and
inactive >1 yr
Stop:
New Lymphoma,
esp EBV on 6MP
54
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
Thiopurine
antiTNF
LYMPHOMA
HSTC Lymphoma
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
SOLID TUMORS
-Has been a fatal
lymphoma.
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future 6MP
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
-Has been a fatal
lymphoma.
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future
antiTNF?
55
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
Thiopurine
antiTNF
LYMPHOMA
HSTC Lymphoma
SOLID TUMORS
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
Continue or start:
-Has been a fatal
lymphoma.
-Previously Rx’d
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future 6MP
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
-Has been a fatal
lymphoma.
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future
antiTNF?
-even active (nonEBV) solid tumors
ok to continue
56
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
Thiopurine
antiTNF
LYMPHOMA
HSTC Lymphoma
SOLID TUMORS
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
Continue or start:
-Has been a fatal
lymphoma.
-Previously Rx’d
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future 6MP
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
-Has been a fatal
lymphoma.
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future
antiTNF?
-even active (nonEBV) solid tumors
ok to continue
Start:
Previously Rx’d
57
Malignancy: Stop or Continue? What I do
Consult with Oncology and then.….
Thiopurine
antiTNF
LYMPHOMA
HSTC Lymphoma
SOLID TUMORS
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
Continue or start:
-Has been a fatal
lymphoma.
-Previously Rx’d
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future 6MP
Continue or start:
Previously Rx’d and
inactive >1 yr
Must Stop:
-Has been a fatal
lymphoma.
Stop:
New Lymphoma,
esp EBV on 6MP
-Even if eradicated,
avoid future
antiTNF?
-even active (nonEBV) solid tumors
ok to continue
Start:
Previously Rx’d
Stop:
Active cancer
(but unless mets, ok
to restart once rx’d?)
58
I think skin AEs are increasing
and becoming most problematic
Related to
the IBD
Skin
manifestations
of IBD
Secondary to
medical
therapy
Consequence
of nutritional
deficiencies
Skin AEs secondary
to Meds
- Malignancy
- Immune mediated
-Thank you, Jean Fred
for your slides
60
Do GI’s know Skin?
61
Basal Cell Cancer
Plantar Psoriasis
Nodular Pigmented BCC
Squamous Cell Ca
62
Take home message:
Get Dermatology involved!
63
What’s the dx? Stop or Cont
ADA?
• 67 yo m CD remission 3 yrs ADA – has
15 of these lesions removed over past 2
years
64
Stop or Continue – Basal Cell CA
• 67 yo m CD remission 3 yrs ADA – 15
basal cells removed over past 2 years
• He opts to continue ADA given good CD
response.
• He follows closely with derm – for
smaller lesions topical 5FU has been
effective.
65
What is this? What do you do?
• 59 yo f CD sun exposure entire life –
deep remission on 6MP for 15 years
• Last 2 yrs has had Moh’s surgery x 2 to
remove these lesions from face – 3 from
neck
66
Stop or Continue – Squamous
Cell cancer
• The 6MP is stopped and in the next 2
years she has had 1 more SCC but her
CD remains in remission
67
High Rates of BCC and SCC in IBD pts exposed to
thiopurines – active or previous exposure
Yearly incidence rate (per 1,000 patient-years)
32 incident NMSC: 20 BCC and 12 SCC
6
>65 years
Thiopurine therapy
5.70
Continuing
5
Discontinued
50-65 years
3
2.59
<50 years
2
1.96
1
0.84
0.66
0.60
0.38
0
Cases of NMSC (n)
Patient-years
4.04
Never received
4
0
9
3
0
13590 7924 15736
6
3
3
3
3
2
2319
1530
4968
743
526
2383
Peyrin-Biroulet. Gastroenterology 2011
Anti-TNFs also associated with Basal Cell and
Squamous Cell Cancers
• Prospective observational
registries and studies
• Patients with RA, PsA or
ankylosing Spondylitis
receiving TNFi therapy
Patients treated with TNFi
have a significantly
increased risk of
developing an NMSC
(1.45, 95% CI 1.15 to
1.76).
Mariette X. Ann Rheum Dis. 2011
Melanoma and anti-TNF therapy in IBD
• Retrospective cohort (and nested casecontrol) study
• LifeLink claims database  108,518 IBD
pts
• Crohn’s (but not UC) associated with
increased risk of melanoma (IRR 1.45,
OR 1.88 (95% CI 1.08-3.29)
95% CI 1.13-1.85)
• Biologics increased risk of melanoma
Long M, et al. Gastroenterology 2012. Epub ahead of print.
What is your dx? How do you rx?
• 27 yo female CD on ADA in remission
for 3 yrs but over past 6 mos develops
progressive skin lesions over ears and
scalp (with hair loss)
74
Anti-TNF psoriaform lesions – in
my opinion the most common and
difficult antiTNF AE to manage
• She sees dermatology who tries topical
treatment (steroids, dapsone) without
benefit.
• They recommend adding MTX but she
wants to have children soon
• She stops the ADA. Her skin improves
and 1 yr later she is pregnant but is
beginning to have CD sx’s.
75
What about this case? Fungal? Other?
• 25 yo male UC on IFX in remission but
over past 6 mos has patchy skin lesions
under the arms and gluteal cleft
76
“Inverse Psoriasis” from antiTNF
• His skin improves with topical
steroids/dapsone but not completely
• After adding MTX 10mg per week the
lesions resolve.
77
Psoriasis associated with Anti-TNF therapy
• Described with all the anti-TNF: class effect
• Described in patients receiving treatment for diverse indications (RA, IBD,
psoriasis, psoriatic arthritis, ankylosing spondylitis)
• Often leads to therapy discontinuation
• First IBD case reported in 2004 in a CD patient treated with infliximab
150
Increasingly recognised
side-effect of anti-TNF
therapy in the IBD literature
18
November 2008 (1)
(2)
August 2011
Verea MM. Ann Pharmacther 2004; (1) G. Fiorino. APT 2009; (2) Cullen G. In press 2011
Psoriasis associated with Anti-TNF therapy
FDA WARNING
Psoriasis associated with Anti-TNF therapy
What is the magnitude of the problem in IBD patients?
Psoriasis associated with Anti-TNF therapy in IBD: a new series and review of
120 cases from the Literature
Case reports (50) + current series(30) + GETAID Series (62)
150 cases for analysis
Psoriasis details
Location:
•Palmoplantar - 42%
•Scalp - 42%
•Trunk – 31%
•Flexures – 31%
•Facial – 16%
Cullen G. APT 2011
When you see this –
think antiTNF mediated Psoriasis
• Several phenotypes:
• Palmoplantar pustular psoriasis: form most commonly associated
with anti-TNF therapy (even in patients treated for plaque psoriasis)
JF Rahier.CGH 2010; Courtesy of Franck Delesalle
….or this……antiTNF Psoriasis
• Several phenotypes:
• Inverse psoriasis (type of psoriasis in plaques)
In Psoriasis – Manson publishing; Courtesy of Franck Delesalle
Skin: Stop or Continue? What I doConsult with Dermatology and then.….
NMSC – Basal Cell
Squamous Cell
Melanoma
PSORIASIAS-like
(Immune mediated)
Thiopurine
antiTNF
87
Skin: Stop or Continue? What I doConsult with Dermatology and then.….
NMSC – Basal Cell
Squamous Cell
Melanoma
PSORIASIAS-like
(Immune mediated)
Thiopurine Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Only if significant
recurrence or potential for
disfiguring sequelae
antiTNF
88
Skin: Stop or Continue? What I doConsult with Dermatology and then.….
NMSC – Basal Cell
Squamous Cell
Melanoma
PSORIASIAS-like
(Immune mediated)
Thiopurine Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Only if significant
recurrence or potential for
disfiguring sequelae
antiTNF
Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Rarely necessary
89
Skin: Stop or Continue? What I doConsult with Dermatology and then.….
NMSC – Basal Cell
Squamous Cell
Thiopurine Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Only if significant
recurrence or potential for
disfiguring sequelae
antiTNF
Melanoma
PSORIASIAS-like
(Immune mediated)
Continue/start:
-eradicated
-melanoma free
for > 1 yr
-no mets
Stop:
New Onset?
Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Rarely necessary
90
Skin: Stop or Continue? What I doConsult with Dermatology and then.….
NMSC – Basal Cell
Squamous Cell
Thiopurine Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Only if significant
recurrence or potential for
disfiguring sequelae
antiTNF
Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Rarely necessary
Melanoma
PSORIASIAS-like
(Immune mediated)
Continue/start:
-eradicated
-melanoma free
for > 1 yr
-no mets
Stop:
New Onset?
Continue/start:
-eradicated
-melanoma free
for > 1 yr
-no mets
Stop:
New Onset
91
Skin: Stop or Continue? What I doConsult with Dermatology and then.….
NMSC – Basal Cell
Squamous Cell
Thiopurine Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Only if significant
recurrence or potential for
disfiguring sequelae
antiTNF
Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Rarely necessary
Melanoma
PSORIASIAS-like
(Immune mediated)
Continue/start:
-eradicated
-melanoma free
for > 1 yr
-no mets
Continue or start:
Stop:
New Onset?
-any psoriasis, past or
present
- MTX may be useful in
rxing antiTNF-mediated
skin ds
Continue/start:
-eradicated
-melanoma free
for > 1 yr
-no mets
Stop:
New Onset
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Skin: Stop or Continue? What I doConsult with Dermatology and then.….
NMSC – Basal Cell
Squamous Cell
Thiopurine Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Only if significant
recurrence or potential for
disfiguring sequelae
antiTNF
Continue or start:
Active or Past, as long as
Dermatology monitoring
Stop:
Rarely necessary
Melanoma
PSORIASIAS-like
(Immune mediated)
Continue/start:
-eradicated
-melanoma free
for > 1 yr
-no mets
Continue or start:
Stop:
New Onset?
Continue/start:
-eradicated
-melanoma free
for > 1 yr
-no mets
Stop:
New Onset
-any psoriasis, past or
present
- MTX may be useful in
rxing antiTNF-mediated
skin ds
Continue:
Mild, <5% skin, responds
to topical tx or MTX
Stop:
>5%, nonresponsive to
psoriasis tx
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Summary: Stop or Continue Rx?
• IMMs and biologics are associated with
rare, but potentially serious AEs
• Most AEs do not mandate IMM/antiTNF
cessation – individualize the decision
• I would stop/hold IMM/antiTNF for:
–
–
–
–
–
Active opportunistic infections (rare)
Lymphoma/Cancer (very rare)
Recurrent skin cancers
Non-responsive psoriasis to antiTNF
Allergic/idiosyncratic drug rxns
• Once AE resolves, usually restart meds
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UPMC IBD Center: Physicians and Staff
When you go out tonight, beware of:
Bill Sandborn and Jean Fred Colombel
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