Atopic dermatitis patient reports acute Arthritis and polyarthralgia after using Dupilumab
Dupilumab is the first FDA approved injectable indicated for the treatment of adults with moderate to severe atopic dermatitis (AD) whose disease is not adequately controlled by topical prescription therapies. Recently a case of a 38-years-old woman with atopic dermatitis who developed acute mono-arthritis of the ankle and generalized polyarthralgia immediately after initiating dupilumab treatment was reported in the journal, Clinical and Experimental Dermatology. The case reported adverse drug reaction (ADR) after administration of dupilumab which included serum sickness (-like reaction) [SS(LR)], peripheral spondyloarthropathy (SpA), and rheumatoid arthritis (RA).
Methotrexate (MTX) therapy for AD had been discontinued 1 week before the start of dupilumab treatment because of decreasing effectiveness. Four weeks after starting dupilumab, the patient reported improvement of her eczema; however, she also reported severe joint pain and morning stiffness in one ankle, which gradually spread to her knees, hips, and elbows. These problems started a few days after the first dupilumab injection. She had not contacted us earlier because she was relieved by the rapid decrease in itch complaints. There was no history of previous joint pain and no family history of rheumatic diseases and the patient’s medical history was contributory.
Rheumatological examination revealed tenderness of the wrists, knees, and ankles. The right ankle was slightly swollen and warm. Laboratory investigations showed increases in inflammatory markers: C-reactive protein 33 mg/L (normal value <10 mg/L) and erythrocyte sedimentation rate 63 mm/h (0–20 mm/h). Additional tests including serology screens for parvovirus B19, Epstein–Barr virus, Chlamydia trachomatisand Streptococcus were all negative.
Radiograph of the right ankle showed swollen tissue, without erosions or osteoarthritis. Monoarthritis of the right ankle and inflammatory polyarthralgia as an adverse drug reaction to dupilumab were suspected, and dupilumab treatment was discontinued. The patient was started on a 1-month course of celecoxib 200 mg twice daily and prednisolone 15 mg daily for the joint pain, following which arthritis and arthralgia disappeared. Six weeks after discontinuation of dupilumab, MTX (20 mg weekly, subcutaneously) was started because the patient’s eczema flared. After 2 months, her eczema was controlled and the inflammatory markers had decreased.
So far this is the third case which has reported SS(LR) as an ADR of dupilumab. However, in this case, the patient denied any important hallmark of SS(LR) such as fever, malaise, and urticarial eruption. Moreover, the case-study also stated that the rapid onset of arthritis was typical of SS(LR).
The authors of the case-study also stated that It is reported in prior studies that patients with AD may have a higher risk of developing RA. In addition, dupilumab decreases levels of interleukin (IL)-4, which potentially can increase levels of tumor necrosis factor-a and-6, which are important inflammatory cytokines in the pathogenesis of RA.
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