Development of inflammatory bowel disease during anti-TNF-α therapy for inflammatory rheumatic disease. A nationwide series

Objectives: To describe cases of new onset of inflammatory bowel disease (IBD) in patients with inflammatory rheumatic disease (IRD) receiving anti-TNF-alpha therapy. Methods: A call for observations of such cases was sent to members of the French Club rhumatismes et inflammation. Only patients without intestinal symptoms before introduction of anti TNF-alpha agents were included. Results: During a 2-year period, 16 patients were declared: nine men and seven women, mean age 41.5 +/- 17.4 years, 12 patients with ankylosing spondylitis, one with rheumatoid arthritis, one with psoriatic arthritis and two juvenile idiopathic arthritis with enthesitis related arthritis. Overall, 14 patients received etanercept and two had infliximab. The meantime frame between onsets of anti-TNF-alpha drugs and development of IBD was 29.3 +/- 20.1 months. According to endoscopic and histological findings, IBD was classified as typical Crohn's disease in eight cases, Crohn's-like disease in six cases, indeterminate in one case and definite ulcerative colitis in one case. For all cases, each TNF-alpha blocking agent was discontinued and replaced by another monoclonal anti TNF-alpha antibody. After a mean follow up period of 23.4 +/- 19.5 months, outcome was favorable without recurrent or flaring IBD. Conclusions: Paradoxical IBD may occur during anti TNF-alpha therapy for inflammatory rheumatic disease, mostly in patients with spondylarthropathies while receiving etanercept, at a frequency estimated to 0.15% in the French patients with spondylarthropathies exposed to TNF-alpha antagonists. The IBD mainly corresponded to Crohn's or Crohn's-like disease. On the contrary, new onset IBD is less frequently observed in other cases of IRD and with other TNF-alpha blockers. (C) 2011 Societe francaise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.