Abstract
TNF blockers have rarely been associated with haematological complications; however, there are scattered case reports of marked neutropenia with their use and necessitating in their withdrawal. We would like to report a series of five patients who developed neutropenia with etanercept use; however, all these patients were re-challenged with etanercept with a mean follow up of 30 months. These patients developed neutropenia within 2 months of starting etanercept. Two patients were eventually taken off etanercept; one of them needed switching to a different form of TNF blockers, and the second patient is in clinical remission with low-dose corticosteroids. All our patients continued to have mild–moderate degree of neutropenia; however, they are being monitored very closely and they are enjoying complete disease remission. It was interesting to note that none of our patients had increased infections during the re-challenge phase, even though they had grade 2 to grade 4 neutropenia. We have re-challenged these patients without any clinical complications, revealing that patients with mild to moderate neutropenia can be safely exposed to TNF blockers as long as they are monitored with regular cell count checks. Although largely noted to be clinically insignificant in our patient series, the potential of drug-induced neutropenia in causing higher rate of infections do exist. Careful clinical and hematologic monitoring is the best way to recognize this adverse event.
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References
Ledingham J, Deighton C (2005) Update on the British Society of Rheumatology guidelines for prescribing TNFa blockers in adults with rheumatoid arthritis (update of previous guidelines of April 2001). Rheumatology 44:157–163
Furst DE, Breedveld FC, Kalden JR, Burmester GR, Smolen JS, Bijlsma JWJ et al (2005) Updated consensus on biological agents, specifically tumour necrosis factor a, (TNFa) blocking agents and interleukin-1 receptor antagonist (IL-1ra), for the treatment of rheumatic diseases. Ann Rheum Dis 64:iv2–iv14
Montane E, Salles M, Barriocanal A et al (2007) Antitumor necrosis factor induced neutropenia: a case report with double positive rechallenges. Clin Rheumatol 26:1527–1529
Wenham C, Gadsby K, Deighton C (2008) Three significant cases of neutropenia with etanercept. Rheumatology (Oxford) 47(3):376–377
Ottaviani S, Cerf-Payrastre I, Kemiche F, Pertuiset E (2009) Adalimumab-induced neutropenia in a patient with rheumatoid arthritis. Joint Bone Spine 76(3):312–313
Favalli EG, Varenna M, Sinigaglia L (2005) Drug-induced agranulocytosis during treatment with infliximab in enteropathic spondyloarthropathy. Clin Exp Rheumatol 23:247–250
Rajakulendran S, Gadsby K, Allen D et al (2006) Neutropenia while receiving anti-tumour necrosis factor treatment for rheumatoid arthritis. Ann Rheum Dis 65:1678–1679
Feltelius N, Fored CM, Blomqvist P et al (2005) Results from a nationwide postmarketing cohort study of patients in Sweden treated with etanercept. Ann Rheum Dis 64:246–252
Hastings R, Ding T, Butt S, Gadsby K, Zhang W, Moots RJ, Deighton C (2010) Neutropenia in patients receiving anti-tumor necrosis factor therapy. Arthritis Care Res 62(6):764–769
Safferman AZ, Lieberman JA, Alvir JM, Howard A (1992) Rechallenge in clozapine-induced agranulocytosis. Lancet 339:1296–1297
Atkin K, Kendall F, Gould D, Freeman H, Liberman J, O'Sullivan D (1996) Neutropenia and agranulocytosis in patients receiving clozapine in the UK and Ireland. Br J Psychiatry 169:483–488
Sjostedt A, Conlan JW, North RJ (1994) Neutrophils are critical for host defense against primary infection with the facultative intracellular bacterium Francisella tularensis in mice and participate in defense against reinfection. Infect Immun 62(7):2779–2783
Kuijpers TW (2002) Clinical symptoms and neutropenia: the balance of neutrophil development, functional activity, and cell death. Eur J Pediatr 1:S75–S82
Wolach O, Bairey O, Lahav M (2010) Late-onset neutropenia after rituximab treatment: case series and comprehensive review of the literature. Medicine (Baltimore) 89(5):308–318
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Haroon, M., Daly, M. & Harney, S. Re-challenge with Etanercept in patients with Etanercept-induced Neutropenia. Clin Rheumatol 31, 151–155 (2012). https://doi.org/10.1007/s10067-011-1822-2
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DOI: https://doi.org/10.1007/s10067-011-1822-2