Are Anti-TNF-α Agents Safe for Treating Psoriasis in Hepatitis C Virus Patients with Advanced Liver Disease? Case Reports and Review of the Literature

Abstract

Tumor necrosis factor-alpha (TNF-α) inhibitors represent an effective treatment for severe psoriasis in hepatitis C virus (HCV) patients. The literature reports mainly on short-term treatment in patients with chronic hepatitis with minimum-to-moderate activity with an acceptable safety profile. We report the first 2 cases of hepatocellular carcinoma (HCC) arising in HCV psoriatic patients with advanced liver disease during long-term treatment with etanercept. Our first patient, known to have had HCV infection for 41 years, developed an HCC after 21 months of therapy with etanercept (50 mg/week). The second patient, HCV+ for 20 years, was treated for 58 months with the same therapy, and despite no signs of liver function impairment was diagnosed with HCC. Both of them presented with cirrhosis, which was diagnosed 9 and 5 years earlier, respectively. It remains to be clarified whether there is any connection between psoriasis treatment with anti-TNF-α agents and the development of HCC in HCV-infected patients. Further long-term, follow-up studies and registries of HCV patients with mild/moderate activity may contribute to clarify this issue.

Adalimumab is a safe option for psoriasis patients with concomitant hepatitis B or C infection: a multicentre cohort study of 37 patients and review of the literature

“…Chronic HCV is a risk factor for cirrhosis and hepatocellular carcinoma (HCC), and immunosuppression might accelerate this progression. Recently, Di Nuzzo et al . reported two cases of HCC developing in HCV psoriatic patients with cirrhotic disease during treatment with etanercept.…”

The unforeseen during biotechnological therapy for moderate‐to‐severe psoriasis: How to manage pregnancy and breastfeeding, infections from Mycobacterium tuberculosis , hepatitis B virus, hepatitis C virus, and HIV , surgery, vaccinations, diagnosis of malignancy, and dose tapering

“…As for M. tuberculosis , also for HBV and HCV, TNF‐α plays an important role in helping the clearance of the viruses from infected hepatic cells 27 . Moreover, according to some authors, patients with positive HCV infection that received anti‐TNF‐α therapy did not experience any worsening of liver function or viral load during the treatment 28,29 . According to Zein et al, etanercept might be used as adjuvant to HCV treatments such as ribavirin and interferon in reducing liver fibrosis due to the viral infection 30 .…”

Liver Illness and Psoriatic Patients

“…The aforementioned systematic review found HCV reactivation only in 3 out 97 patients with psoriasis under bDMARDs treatment, without evidence of hepatitis exacerbation (3.1%) [ 78 ]. Among bDMARDs, most data concern TNF antagonists: in HCV patients with psoriasis [ 79 ], their use appears safe, although sporadic cases of hepatocellular carcinoma (HCC) have been reported [ 49 ]. This occurrence affected cirrhotic patients: considering that cirrhosis by any cause is itself a remarkable prooncogenic risk factor, it is difficult to establish the role played by TNF inhibitors, which, however, should be used with caution in psoriatic patient with advanced liver disease [ 49 , 79 ]; cDMARDs seem safe in HCV patients with psoriasis as for reactivation [ 49 ].…”

“…Among bDMARDs, most data concern TNF antagonists: in HCV patients with psoriasis [ 79 ], their use appears safe, although sporadic cases of hepatocellular carcinoma (HCC) have been reported [ 49 ]. This occurrence affected cirrhotic patients: considering that cirrhosis by any cause is itself a remarkable prooncogenic risk factor, it is difficult to establish the role played by TNF inhibitors, which, however, should be used with caution in psoriatic patient with advanced liver disease [ 49 , 79 ]; cDMARDs seem safe in HCV patients with psoriasis as for reactivation [ 49 ]. Unfortunately, to the best of our knowledge, specific guidelines on management of psoriatic patients under biological treatment and with concomitant HCV infection are lacking [ 80 ].…”