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    • Topical medications including topical corticosteroid vitamin

    2018-10-25

    Topical medications including topical corticosteroid, vitamin D3 analogs, and anthralin had been used as adjunctive therapies in patients receiving etanercept for psoriasis treatment. In the present study, all patients did not receive systemic medication or phototherapy as a concomitant treatment. Topical medications (e.g., coal tar, topical steroid, or vitamin D3 analogs) were prescribed in 14 (63.6%) patients on their request or due to poorer disease control. In patients treated with concomitant topical medications, the PASI improvement at Week 12 and Week 24 was 48.2% and 53.3%, respectively, which showed worse disease control compared to the groups using etanercept as a monotherapy (p = 0.0002 at Week 12 and p < 0.0001 at Week 24) (Table 5). This result may be attributed to the fact that agomelatine patients with poor psoriasis control needed more therapeutic options. One analysis of three clinical trials using etanercept as a monotherapy in treating psoriasis demonstrated its safety. By Week 12, the most common adverse event was upper respiratory infection (9.5%), followed by headache (8.9%) and injection site ecchymosis (6.4%) in the group with etanercept 50 mg BIW. Percentages of serious adverse events and serious infections were estimated to be 1.1% and 0.3%, respectively. In the current study, 10 (45.5%) patients had upper respiratory infection by Week 12, while no headache or injection site injury occurred. No serious adverse event or infection was noted. In a retrospective analysis of 17 patients with concurrent psoriasis and HBV or hepatitis C, who were treated with anti-TNF-α agents, there was no abnormal liver function or increased viral load. The HBV carrier in the present study also showed no sign of viral reaction. Inflammatory markers for psoriasis had previously been surveyed in one study that enrolled 41 patients treated with etanercept 50 mg BIW. ESR, high-sensitivity CRP, and other markers were measured at baseline and Week 12. By Week 12, all inflammatory markers were reduced (p < 0.001). Interestingly, better improvement of high-sensitivity CRP and ESR was correlated with more PASI 75 responses. All patients in the present study showed reduction of ESR and CRP by Week 12. Furthermore, there was no correlation between PASI 75 achievement and reduced rates of ESR and CRP. A retrospective, observational study by Pink et al elucidated that 16.7% of psoriasis patients developed positive ANA titers on their first treatment with anti-TNF-α agents. When patients failed to respond with more than one anti-TNF-α agent, the possibility of ANA development might increase. In the current study, no patient received anti-TNF treatment previously. Four (18.2%) patients developed positive ANA and one of them (25.0%) had worse psoriasis control. TNF-α antagonist-induced lupus-like syndrome with the induction of autoantibodies is reportedly more commonly associated with etanercept and infliximab. None of the patients in this study had lupus-like syndrome during the treatment course. Several reports have shown that serum TNF-α level may increase after using etanercept for the treatment of diseases other than psoriasis. Although there is more detectable TNF-α in blood, it is not active biologically or immunologically. However, TNF-mediated diseases may occasionally be induced. In the present study, 15 of 16 (93.8%) patients had increased serum TNF-α levels at Week 12. Nonetheless, the clinical response (PASI improvement) is not associated with the change in TNF-α level (R2 = 0.096 and p = 0.72). Furthermore, diseases commonly associated with increased TNF level, such as rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, or heart failure, did not occur in the study patients. Longer follow-up of serum TNF-α level after Week 12 was not complete due to poor patient compliance for blood test and discontinuation of etanercept therapy after 24 weeks. Further large-scale, long-term studies are needed to establish a more comprehensive analysis of the relationships between serum TNF-α level and psoriasis control.