Infections in psoriatic arthritis: association with treatment

Abstract

Serious infections (SIs) remain one of the most significant comorbidities in patients with inflammatory arthritides including psoriatic arthritis (PsA). Apart from methotrexate (MTX) and biologics such as tumor necrosis factor (TNFi), interleukin-12/23 (IL-12/23i), and IL-17 inhibitors (IL-17i), traditionally used for the treatment of PsA, recently biologics such as IL-23i and targeted synthetic agents like JAK inhibitors (JAKi) have been introduced in the daily clinical practice for the treatment of this disease. Although overall the incidence of SIs in patients with PsA treated with these agents is lower compared to patients with rheumatoid arthritis, still a number of unresolved issues regarding their safety remain. Current evidence is reassuring regarding the safety profile of conventional synthetic disease-modifying anti-rheumatic drugs, such as MTX. The increased risk for reactivation of latent infections, such as tuberculosis and hepatitis B virus (HBV) with the use of TNFi, is well described; nevertheless, it is significantly ameliorated with the appropriate screening and prophylaxis. Regarding IL-12/23i and IL-17i, there are no significant safety signals, except from an increased incidence of usually mild Candida infections with the latter class. Newer biologics such as IL-23i and targeted synthetic agents like JAKi have been recently introduced in the daily clinical practice for the treatment of this disease. While IL-23i has not been shown to increase the risk for common or opportunistic infections, a well-established association of JAKi with herpes zoster warrants the attention of rheumatologists. In this narrative review, we summarize the infectious complications of available treatment options by drug class in patients with PsA.

Keywords: JAK inhibitors; biologic therapy; psoriatic arthritis; serious infections.

Figure 1.

Systemic glucocorticoid use and serious infection risk among patients with psoriatic arthritis. GC, glucocorticoid; PsA, psoriatic arthritis.

Figure 2.

Conventional synthetic DMARDs and infection. DMARD, disease-modifying anti-rheumatic drugs; HZ, herpes zoster; MTX, methotrexate; PsA, psoriatic arthritis; RA, rheumatoid arthritis; RCT, randomized controlled trial.

Figure 3.

TNF inhibitors and infection in psoriatic arthritis. LTE, long-term extension; RCT, randomized controlled trial; TNFi: Tumor necrosis factor inhibitors.

Figure 4.

Other DMARDs and infection in psoriatic arthritis. DMARD, disease-modifying anti-rheumatic drugs; HZ, herpes zoster; IL, interleukin; JAK, Janus activated kinase; TB, Tuberculosis; TNFi: Tumor necrosis factor inhibitors.