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A 47 year old man presented with seven years of severe psoriatic polyarticular arthritis of progressive, symmetrical, and additive course, affecting the shoulders, elbows, wrists, metacarpophalangeal joints, proximal interphalangeal joints, distal interphalangeal joints, hips, knees, and feet. Also, his skin and nails were completely affected with severe erythroderma. The patient was treated with methotrexate, chrysotherapy, antimalarial drugs, salazopyrine, azathioprine, cyclosporin, minocycline, and intra-articular and systemic corticosteroids. All these treatments consecutively and in combinations failed or were stopped owing to side effects. During 1999 his condition deteriorated further with morning stiffness of more than six hours, active synovitis of more than 20 joints, and systemic symptoms, such as extreme fatigue and weight loss of more than 10 kg. The patient became confined to a wheel chair. His blood tests disclosed increased erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) levels, and normocytic normochromic anaemia (table 1).
In July 1999 etanercept (25 mg) subcutaneously twice weekly was started. A week later the patient reported a dramatic improvement in his general wellbeing, morning stiffness, and joint pain accompanied by a significant decrease in the number of swollen and tender joints and the erythematous component of the skin lesions. His clinical improvement continued during the following six weeks. He regained 6 kg weight; the ESR decreased to 11 mm/1st h and the haemoglobin concentration increased to 120 g/l (table 1).
Etanercept, a recombinant human tumour necrosis factor (TNF) receptor Fc fusion protein (Enbrel, Immunex Corp, Seattle, Washington) is a dimer consisting of the extracellular portion of two p75 receptors fused to the Fc portion of human IgG1.1 Several trials in patients with active rheumatoid arthritis have shown that etanercept is safe, well tolerated, and produces significant improvement in disease activity.2 ,3
Many studies have shown that TNFα plays an important part in the pathogenesis of psoriatic skin lesions and psoriatic arthritis.4 ,5 The dramatic effect of etanercept in the present resistant and extremely severe case of psoriatic arthritis suggests a possible role for this drug also in the treatment of severe psoriatic arthritis.
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