by Carolyn Chu, MD, MSc, AAHIVS, AAHIVM Chief Medical Officer

April 25, 2023

Featured Literature:

Bang AS, Hakimi M, Tahir P, Bhutani T, Leslie KS.  Biologic therapies in HIV/AIDS patients with inflammatory diseases: a systematic review of the literature.  AIDS Patient Care STDs.  2023 Apr 20.  PMID: 37083455.    

This review focused on efficacy and safety of biologic drugs used to treat inflammatory diseases in people with HIV.  Authors screened literature (inclusive to June 29, 2022) and included 112 studies involving 179 patients (> 80% were on ART).  12 studies described outcomes among 21 patients receiving dupilumab (IL-4 inhibitor), used primarily for atopic dermatitis: 57% experienced complete and 43% partial response.  33% experienced adverse events.  18 case reports/series described rituximab (CD20 inhibitor) among 25 patients, used mostly for kidney or hemolytic disease: response was mixed.  Adverse events occurred in 16%.  4 cases involving IL-5 and IGE inhibitors (mepolizumab and omalizumab, used for asthma and DRESS, and bullous pemphigoid and chronic spontaneous urticaria, respectively) were examined.  All 4 patients were successfully treated with no adverse events.  9 cases involved IL-17 inhibitors (brodalumab, ixekizumab, secukinumab) used for psoriasis and axial spondylarthritis: all had partial or complete response.  2 cases of secukinumab-associated adverse events were observed: candida esophagitis with erosive gastritis, and genital candidiasis—both responded to fluconazole.  Cases involving IL-23 inhibitors (guselkumab, risankizumab, ustekinumab) used primarily for psoriasis among 23 people indicated complete response for 4 and partial improvement for all others, without adverse events.  62 studies of TNF-alpha inhibitors (adalimumab, ethanercept, infliximab) involving 109 patients were included.  Psoriasis was the main indication, followed by rheumatological and gastrointestinal diseases.  Most patients experienced partial or complete resolution, or significant improvement.  23 adverse events were noted, including CD4 decreases, PJP (this person was not on ART at the time), sepsis (CD4 was 20), acute prostatitis, allergic reactions, tuberculosis reactivation, listeria meningitis, and CMV colitis.

Author’s Commentary:

Because people with HIV are often excluded from trials examining the safety and efficacy of biologics, little evidence is available to guide providers on how to counsel patients and there is ongoing hesitancy about their use.  With rapid development of multiple therapeutic classes, more agents are now available and findings from this review suggest nearly all biologic classes are both efficacious and safe when used for inflammatory conditions among people with HIV.  Agents which carry the highest risk for serious adverse events appear to be TNF-alpha and CD20 inhibitors.  Authors also emphasize that HIV screening should be required, rather than discretionary, when initiating and maintaining people on biologics, since undiagnosed and untreated HIV may complicate their use.  

The author has no conflicts of interest to disclose.

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