Inflammatory bowel disease as a paradoxical effect of anti-TNF alpha therapy

Anti-TNF alpha therapies are used in the treatment of different inflammatory conditions as inflammatory bowel disease (IBD). Specifically, IBD is a chronic disease characterized by inflammation of gastrointestinal tract, particularly of colon. It includes Crohn disease and ulcerative colitis.

Anti-TNF drugs have differences in their structure. These variations are not important in musculoskeletal diseases like rheumatoid arthritis, psoriatic arthritis  and ankylosing spondylitis. But they could explain the diversity in the inmune response, in their benefits in IBD and in their adverse effects. Among the secondary effects have been described the paradoxical adverse reactions.  The paradoxical effects mean the production or unmasking of similar diseases to those for which they are used for, such as psoriasis, anterior uveitis, lupus or IBD.

Etanercept is the main anti- TNF agent associated with the development of paradoxical IBD, and, in addition, it has not proven usefulness in the treatment of the disease. This association, which is not accidental, is unfrequent and especially seen in patients with spondyloarthritis. Spondyloarthritis is a group of inflammatory artrhytis diseases  that affects the spine and, sometimes the joints of the arms and legs. Treatment with etanercept closely precedes in time to the onset the symptoms, and its reintroduction may induce new intestinal symptoms.

There are no differences that allow to discern primary and secondary IBD and the diagnostic is made in the same way. Is essential the clinical suspicion in patients with rheumatic diseases treated with anti-TNF who develop intestinal symptoms.

The most frequent presentation is as Crohn’s-like disease with pain in the abdomen and diarrhea.

When a paradoxical event occurs the most widespread treatment is to replace Etanercept with Infliximab (another antiTNF agent). With this strategy recurrences have not been described.

Based in all this, it can be said that this is a rare and little-known phenomenon that if is not known, can hardly be attributed to drugs. For this reason we believe that this article may be relevant to everyday clinical practice.

Iriarte A 1, Zaera C 2, Bachiller-Corral J 3, López-Sanromán A 2
1Department of Gastroenterology, Hospital de Bidasoa, Guipuzcoa, Spain
2Department of Gastrotenterology, Hospital Ramón y Cajal, Madrid, Spain
3Department of Rheumatology, Hospital Ramón y Cajal, Madrid, Spain



Inflammatory bowel disease as a paradoxical effect of anti-TNF alpha therapy
Iriarte A, Zaera C, Bachiller-Corral J, López-Sanromán A
Gastroenterol Hepatol. 2016 Mar 15


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