IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 5, May 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(5):266–269.www.ijcasereportsandimages.com

Anti­IL­12/IL­23 treatment for a psoriatic patient withheart failureAuriemma Matteo, Caponio Chiara, Ruggiero Carlo,Giuliani Federica, Amerio Paolo

ABSTRACTIntroduction: Psoriasis is an inflammatorydisorder characterized by a deregulation in theTh1/Th17/Treg cells count and function. Aplethora of new drugs called “biologicals” havebeen developed. Beside TNF­α blockers, newdrugs interfering with the IL­23 axis have beenintroduced. Case Report: We present case of: a59­year­old high­need psoriatic patienthospitalized for acute heart failure. Physiciansdecided to withdraw anti­TNF­α therapybecause of NYHA class III and the need ofcardio­surgery. Surgery was delayed for hisgeneral conditions. The patient was referred toour department to establish a new therapy. Atreatment with anti­IL­12/IL­23p40 wasintroduced. Ustekinumab was chosen for thehigh efficacy rates, the high safety profile andfor the reported safety in NYHA class III/IVpatients. The rapid general conditionimprovement enabled the patient to undergo

surgery. Conclusion: Anti­TNF­α drugs arecontraindicated in NYHA class III/IV patients.In those cases drugs interfering with differentcytokine patterns could be of interest. Althoughanti­IL­12/IL­23p40 has been previouslyaddressed as unsafe in NYHA class III/IV, theclinical practice suggests that this drug can beconsidered quite safe. Currently the role of anti­IL­12/IL­23p40 on cardiovascular diseases isstill an open question and deserves furtherinvestigations. Treatment with anti­IL­12/IL­23p40 can be considered a good option in NYHAclass III/IV patients and in high­ need psoriasispatients.Keywords: Psoriasis, MACE, Anti­IL­12/IL­23p40, Ustekinumab

*********Matteo A, Chiara C, Carlo R, Federica G, Paolo A. Anti­IL­12/IL­23 treatment for a psoriatic patient with heartfailure. International Journal of Case Reports andImages 2013;4(5):266–269.

*********doi:10.5348/ijcri­2013­05­309­CR­6

INTRODUCTIONPsoriasis is a systemic inflammatory disorderassociated with several comorbidities (metabolic,cardiac and psychiatric). Several immunologicalmechanisms are involved in pathogenesis of psoriasis. Aderegulation of Th1, Th17 and regulatory T cells (Tregs)results in persistent T­cell activation and highexpression level of proinflammatory cytokines such astumor necrosis factor­α (TNF­α), interferon­γ (IFN­ γ)and interleukins like IL­12, IL­17 and IL­23 and theirreceptors [1].

CASE REPORT OPEN ACCESS

Auriemma Matteo1 , Caponio Chiara2, Ruggiero Carlo3,Giul iani Federica3, Amerio Paolo4

Affi l iations: 1 (MD, PhD student), Department ofExperimental and Clinical Sciences, Dermatologic Clinic,G. d’Annunzio University, Chieti , I taly; 2(MD, resident),Department of Medicine and Aging Science (DMSI),Dermatologic Clinic, G. d’Annunzio University, Chieti , I taly;3(MD, fel low), Department of Medicine and Aging Science(DMSI), Dermatologic Clinic, G. d’Annunzio University,Chieti , I taly; 4(PhD, MD, director), Department of Medicineand Aging Science (DMSI), Dermatologic Clinic, G.d’Annunzio University, Chieti , I taly.Corresponding Author: Matteo Auriemma, DermatologicClinic, SS Annunziata Hospital, Via Dei Vestini , ChietiScalo (Chieti), 661 00, I taly; Phone: +39 (0) 871 358032;Fax: +39 (0) 871 551 057; E-mail :matteo.auriemma@gmail .com

Received: 04 September 201 2Accepted: 08 December 201 2Published: 01 May 201 3

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A plethora of new drugs called “biologicals” havebeen developed. These interfere with the pathologicalmechanism of psoriasis, directly blocking orantagonizing several cytokines. Two main class exist:TNF­α­blockers and anti­IL­12/IL­23.Ustekinumab is the latest “biological” approved byFDA for the treatment of moderate to severe plaquepsoriasis. The main target of this drug is the IL­12/IL­23p40 subunit thus interfering with Th17 maintenanceand inflammation progression [2]. High efficacy ratescoupled with a good safety profile are the mainadvantages of ustekinumab. Anti­TNF­α agents havebeen addressed as unsafe in NYHA class III/IV patientsand are contraindicated in these conditions. However,some studies in rheumatoid arthritis (RA) patients inNYHA class III/IV treated with biologics, seem tosuggest a possible role of those drugs not only incontrolling RA or psoriasis but also in ameliorating thecardiologic condition. New “biologic” drugs (e.g. anti­IL­12/IL­23p40) does not seem to have a negativeimpact on NYHA class III/IV patients and are currentlydescribed as a good option in the treatment of high needpatients with cardiac failure or cardiac failurepredisposing conditions. Clinical surveillance is neededto assess the safety of the drugs in high need patients.We describe this paradigmatic case to underline theimportance of ustekinumab in patients with cardiacdiseases.

CASE PRESENTATIONIn December 2011, a 59­year­old male was referredto the outpatient clinic with a severe psoriaticerythroderma. The patient suffered from psoriasis sincethe age of 18 years. He had no familiar history ofpsoriasis. His past medical history revealed deep veinthrombosis (two episodes treated with thrombectomy),epilepsy, type II diabetes, chronic renal failure (sinceyear 2000) and hepatosteatosis. He quit smoking 25years ago and did not drink alcohol. No drug allergieswere reported.Since first presentation of psoriasis, the patientunderwent topical treatments, several UVB­narrowband (NB) courses with good responses. When hispsoriasis worsened he was treated with two retinoidcourses, cyclosporine (4 mg/kg/day) and methotrexate(15 mg/week) for several courses with only temporaryimprovement and worsening of the hepato­steatosis andserum lipid levels.At this time (about six years ago) his psoriasis areaand severity index score was 21 and he begun the firstmonoclonal antibody therapy. After nine months oftherapy infliximab was withdrawn because of lack ofefficacy. For a new psoriasis flare up, the patient wasswitched to a second monoclonal antibody, etanercept,50 mg once­a­week achieving a significant ameliorationof skin presentation (PASI score 90 after three months).At this time his daily therapy included bisoprolol 125mg, pantoprazole 20 mg, potassium canrenoate 100 mg,allopurinol 300 mg, fenobarbital 100 mg, furosemide

125 mg and acetylsalicylic acid 100 mg daily andmetformin 500 mg twice daily.In August 2010, while still under etanercepttreatment, he was admitted to a secondary hospital foran acute heart failure secondary to bronchopneumonia.During hospitalization a diagnosis of severe heartinsufficiency due to valvular heart disease (aortic andmitral valve) was made. Because of the cardio­pulmonary (NYHA class III) conditions, and thenecessity of surgery (aorto­mitral valve replacement),physicians decided to withdrawn anti­TNF therapy assuggested in different international guidelines.However, due to the patient’s general inflammatorycondition, surgery was postponed.The patient was then referred to our department. Atthis time PASI score was 31.3 and BSA was 76% (Figure1). Blood tests were representative for a severeinflammatory state: ESR 96 mm/1st hr CRP 11.70mg/dL, ANA 1/160 (homogeneous pattern), ASLO 212IU/mL, RBC count 3.19x106/mm3; Hb 9.5 g/dL, hct30.5%; TLC 13.0x103/mm3 and lymphocyte count1.15x103/mm3. Chest X­ray was unremarkable: Mantouxtest (PPD) and quantiferon were all negative.After a through evaluation of the immunological,serological and cardiac condition it was decided to starta new treatment with ustekinumab subcutaneously atstandard dose (45 mg every 4 weeks for the first monthand then every three months) (patient’s height 172 cm;weighs 68 kg; BMI 22.99 kg/m2). In January 2012, after4 weeks, inflammatory markers lowered significantly(CRP 6.79 mg/dL, ESR 76 mm). PASI score decreased to19.5/1st hr and BSA was 30% (Figure 2), leading to amarked improvement in general condition. A secondsubcutaneous injection of ustekinumab was thenadministered. The patient has reported no infections orany other complications and his cardiac condition werestable although still severe. Due to the high need of this

Figure 1: Sub­erythrodermic psoriasis. Psoriasis area andseverity index was 31.3 and BSA was 76%. Afterdiscontinuation of the first monoclonal antibody.

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patient an additional check­up was done on February2012. A more pronounced improvement of PASI andBSA score was achieved (8.3 and 15% respectively)together with further lowering of inflammatory markers(ESR 65 mm/1st hr, CRP 4.81 mg/dL). The patientunderwent surgery for heart­valve replacement inFebruary 2012 and at the last follow­up in April 2012 hisgeneral conditions were good and psoriasis was undercontrol (PASI score 8).

DISCUSSIONMany reports show that IL­12 and IL­23 play a keyroles in the development of psoriasis, inducing INF andTNF producing T cells and stabilizing Th17 phenotype,determining the secretion of cytokines responsible forthe prototypical skin modifications in the psoriaticplaques [3, 4].Ustekinumab, blocking p40 subunit of IL­12/IL­23,interferes with this inflammatory pathways.Ustekinumab has been approved in Europe for thetreatment of moderate to severe psoriatic patients. Tworandomized, double­blind, placebo controlled Phase IIItrials have demonstrated ustekinumabs excellent PASIachievements and good safety profile. Serious adverseevents included severe infections, malignancies andcardiovascular diseases [5].Treatment of severe psoriasis in patients withcardiovascular morbidity and with cardiac insufficiencyhas been always a challenge, especially becausetreatment with anti TNF is contraindicated in patientswith NYHA class III­IV cardiac insufficiency.However, some reports investigated the safety ofbiological drugs for inflammatory condition in NYHA­class­III­IV­patients. Additionally, in the past decade alink between cardiovascular events and inflammatory

autoimmune disorders like psoriasis, RA and crohn’sdisease has been hypothesized and investigated.Unfortunately preliminary reports on anti­IL­12/IL­23p40 (ustekinumab and briakinumab) safety in thetreatment of psoriasis patients showed a numericalexcess of major adverse cardiovascular events (MACE)[6].More recently a meta­analysis of 22 randomizedcontrolled trials evaluating cardiovascular safety of anti­TNF (etanercept, adalinumab and infliximab) and anti­IL­12/IL­23p40 (ustekinumab) in the treatment ofpsoriasis showed that both “classes of biological drugs”did not significantly increase the risk of MACEs [7]. Alittle number of cardiovascular events possiblyassociated with the general increased cardiovascular riskwere observed in some patients. Another recent paperalso reported that cardiac­adverse­events­rates inpatients treated for four years with ustekinumab weresimilar to those of the general population, indicating agood safety profile of the drug [5]. This body ofliterature seems to address the importance ofinflammation in the development of cardiovasculardisease (CVD) and suggests that therapies aimed atreducing disease activity in chronic inflammatorydiseases may also have a positive impact on CVD risk byreducing the burden of systemic inflammation andprogression of atherosclerosis. In psoriasis patients thereduction of inflammation is usually associated withserum C­reactive protein (a known risk factor for CVD)reductions, particularly in the case of using anti­IL­12/IL­23 agents [8].However, the role of IL­12 or IL­23 in thepathogenesis of cardiac failure is still underinvestigation. In case their role would be confirmed,more accurate studies on anti TNF­α and anti IL­12/IL­23p40 MACE safety profile would be mandatory tobetter understand the safety profile of those biologicaldrugs in psoriasis patients with cardiac comorbidities.

CONCLUSIONThe role of anti TNF­α and anti IL­12/IL­23p40 oncardiovascular diseases is still an open question.Although their is lack of exhaustive data on there issafety of biological drug use in case of NYHA class III­IVpsoriasis patients, ustekinumab can be used due to thehigh therapeutic index, rapid mode of action and thegood safety profile. However, anti­IL­12/IL­23p40 andanti­TNF­α should be better assessed for the use inNYHA class III­IV­psoriasis patients in which moretraditional therapies failed to gain good results inreducing PASI and Dermatology Life Quality Index(DLQI) score.

*********Author ContributionsAuriemma Matteo – Substantial contributions toconception and design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising it

Figure 2: Clearance of psoriatic lesions. psoriasis area andseverity index score 19.5; BSA 30% four weeks after IL­12/IL­23 p40 administration.

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critically for important intellectual content, Finalapproval of the version to be publishedRuggiero Carlo – Acquisition of data, Drafting thearticle, Revising it critically for important intellectualcontent, Final approval of the version to be publishedGiuliani Federica – Acquisition of data, Drafting thearticle, Revising it critically for important intellectualcontent, Final approval of the version to be publishedAmerio Paolo – Acquisition of data, Drafting the article,Revising it critically for important intellectual content,Final approval of the version to be publishedGuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© Auriemma Matteo et al. 2013; This article isdistributed under the terms of Creative CommonsAttribution 3.0 License which permits unrestricted use,distribution and reproduction in any means providedthe original authors and original publisher are properlycredited. (Please see www.ijcasereportsandimages.com/copyright­policy.php for more information.)

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