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Successful Treatment of Rheumatoid Vasculitis-Associated Foot-drop with Infliximab: Drs. Richette and Bardin reply
To the Editor:
We read with interest the letter of Dr. Armstrong and colleagues describing successful treatment of rheumatoid vasculitis-associated mononeuritis with infliximab. We would stress that our case report is not isolated. Several authors have described patients developing vasculitis during treatment with either infliximab or etanercept1-6. Most of the described cases were leukocytoclastic vasculitis, but Jarrett, et al also reported a patient with neurological manifestations6. Even if these cases suggest a relationship between tumor necrosis factor-a (TNF-a) blockade and vasculitis, the association is not definitive.
In contrast with this possible side effect, anti-TNF-a has been proposed for management of various systemic vasculitis, and dramatic improvements have been reported. In our opinion, it is still difficult to assess the role of TNF-a blockers in the management of vasculitis since reports have been mainly case reports or uncontrolled studies. A negative randomized placebo-controlled trial with etanercept in Wegener's granulomatosis was reported at the 2004 American College of Rheumatology meeting7.
Finally, we would emphasize the need for caution in the use of anti-TNF-a agents for treatment of rheumatoid vasculitis. Guillevin, et al have suggested that TNF antibody use should be restricted to patients with vasculitis refractory to steroids and immunosuppressant agents8. Randomized controlled studies are required to clarify the role of anti TNF-a in the treatment of rheumatoid vasculitis.
It is important to recognize this potential side effect as, if confirmed, discontinuation of TNF-a inhibitors should be considered. This presumably rare side effect should not discourage the use of anti-TNF-a agents for the treatment of RA.
PASCAL RICHETTE, MD, PhD; THOMAS BARDIN, MD, Fédération de Rhumatologie, Hôpital Lariboisière, 2 rue Ambroise Paré, 75010 Paris, France.
REFERENCES
1. Galaria NA, Werth VP, Shumacher HR. Leukocytoclastic vasculitis due to etanercept. J Rheumatol 2000;27:2041-3.
2. Livermore PA, Murray KJ. Anti-tumour necrosis factor therapy associated with cutaneous vasculitis. Rheumatology Oxford 2002;41:1450-2.
3. Cunnane G, Warnock M, Fye KH, Daikh DI. Accelerated nodulosis and vasculitis following etanercept therapy for rheumatoid arthritis. Arthritis Rheum 2002;47:445-9.
4. McCain ME, Quinet RJ, Davis WE. Etanercept and infliximab associated with cutaneous vasculitis. Rheumatology Oxford 2002;41:116-7.
5. Mohan N, Edwards ET, Cupps TR, et al. Leukocytoclastic vasculitis associated with tumor necrosis factor-alpha blocking agents. J Rheumatol 2004;31:1955-8.
6. Jarrett SJ, Cunnane G, Conaghan PG, et al. Anti-tumor necrosis factor-alpha therapy-induced vasculitis: case series. J Rheumatol 2003;30:2287-91.
7. The WGET research group. The Wegener's Granulomatosis Etanercept Trial (WGET): Randomized, double-masked, placebo-controlled trial of etanercept for the induction and maintenance of remission [abstract]. Arthritis Rheum 2004;50 Suppl:S1719.
8. Guillevin L, Mouthon L. Tumor necrosis factor alpha blockade and the risk of vasculitis. J Rheumatol 2004;31:1885-7.
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