Case Study: Monitoring Needed for Patients With Both UC, AS Receiving Biosimilar Infliximab Treatment

Physicians from Loma Linda University Medical Center and the Veterans Affairs (VA) Loma Linda Healthcare System, writing in the Journal of Clinical Rheumatology, described a patient who developed auricular polychondritis while being treated with a biosimilar tumor necrosis factor (TNF) alpha inhibitor.

The 45-year-old man, who had HLA-B27-positive ankylosing spondylitis and ulcerative colitis (UC), had been receiving the biosimilar infliximab-dyyb (Inflectra) for 3 years at the time the symptoms appeared. Prior to the use of Inflectra and development of polychondritis, the patient had previously experienced lack of efficacy with “all the other anti-TNF medications,” according to the authors.

The authors said their patient presented with redness, warmth, and pain in the ears that had lasted for 3 days, plus intermittent fever, night sweats, sore throat, and photophobia. They admitted him, and first treated him with broad-spectrum antibiotics for possible cellulitis. His symptoms did not improve and infection was ruled out. He was subsequently diagnosed with polychondritis and treated with prednisone and methotrexate. Treatment continued for 4 weeks until the ear pain and redness resolved.

After the resolution of polychondritis symptoms the physicians decided to switch the patient from infliximab-dyyb to ustekinumab, “given the adverse reaction and for better control of his ulcerative colitis.”¹ Ustekinumab (Janssen’s Stelara), a monoclonal antibody targeting interleukin-12 (IL-12) and interleukin-23 (IL-23), was approved by the FDA in 2019 for treating moderate-to-severe UC. In a clinical trial, ustekinumab was superior to placebo at inducing and maintaining clinical remission in patients with UC who had previously had either an inadequate response or unacceptable side effects from other therapies, including anti-TNF biologics.²

The authors commented, “ankylosing spondylitis and polychondritis have rarely been reported concomitantly in the literature, and it is unclear why it presents in patients with other autoimmune diseases.” Among patients who develop polychondritis, about one-third have another autoimmune disease.³

The authors cited previous case reports of polychondritis in patients with spondyloarthritis being treated with anti-TNF agents, either etanercept or infliximab. Another reported polychondritis in a patient with ankylosing spondylitis being treated with the IL-17-inhibitor secukinumab. However, they said, “to our knowledge, this is the first reported case of a patient with ankylosing spondylitis developing polychondritis while getting treated with infliximab biosimilar, Inflectra.”

References

1. Duro T, Li S, Jose D, Khawar T. Polychondritis in a Patient With Ankylosing Spondylitis on an Anti-TNF-α Biosimilar Agent. J Clin Rheumatol. 2021;27(8S):S656. doi:10.1097/RHU.0000000000001650
2. Sands BE, Sandborn WJ, Panaccione R, et al. Ustekinumab as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med. 2019;381(13):1201-1214. doi:10.1056/NEJMoa1900750
3. Emmungil H, Aydın SZ. Relapsing polychondritis. Eur J Rheumatol. 2015;2(4):155-159. doi:10.5152/eurjrheum.2015.0036