How does a history of bronchial asthma, past moderate smoking, and recent bronchiectasis diagnosis impact the use of risankizumab (IL-23 inhibitor) for psoriatic arthritis?

Impact of Bronchial Asthma, Past Smoking, and Bronchiectasis on Risankizumab Use for Psoriatic Arthritis

The presence of bronchial asthma, past moderate smoking, and bronchiectasis does not contraindicate the use of risankizumab (IL-23 inhibitor) for psoriatic arthritis, but requires careful monitoring for respiratory symptoms due to potential increased risk of respiratory infections in patients with bronchiectasis. 1

Assessment of Pulmonary Comorbidities and Their Impact

Bronchiectasis Considerations

• Bronchiectasis is characterized by permanent dilatation of bronchi and is associated with chronic productive cough and recurrent respiratory infections 1
• Patients with bronchiectasis have increased susceptibility to respiratory infections, which may be a concern when using immunomodulatory therapies 1
• The recent bronchoscopy finding of bronchiectasis without significant infective agents is reassuring but requires ongoing monitoring 1

Asthma and Smoking History

• History of bronchial asthma represents an underlying airway disease that may increase respiratory vulnerability 1
• Past moderate smoking history, while not an active concern, has likely contributed to airway damage 1
• The combination of asthma and bronchiectasis represents overlapping airway pathologies that require consideration when selecting immunomodulatory therapy 1

Risankizumab Safety Profile in This Context

General Safety Considerations

• IL-23 inhibitors like risankizumab have not shown specific contraindications for patients with respiratory conditions 1
• The most common adverse event with risankizumab is upper respiratory tract infection, which warrants attention in a patient with pre-existing bronchiectasis 2, 3
• Guidelines recommend using caution in patients with pre-existing immunosuppression-related conditions (expert opinion) 1

Specific Monitoring Recommendations

• More vigilant monitoring for respiratory symptoms and infections is warranted in this patient with bronchiectasis 1
• Consider baseline pulmonary function testing before initiating therapy 1
• Establish a lower threshold for intervention with antibiotics if respiratory symptoms develop 1

Treatment Decision Algorithm

Factors Supporting Risankizumab Use

• Risankizumab has demonstrated high efficacy in psoriatic arthritis with durable long-term response 2, 3
• For patients with clinically relevant skin involvement in psoriatic arthritis, IL-23 inhibitors are specifically recommended by EULAR guidelines 1
• The absence of active infection on bronchoscopy is reassuring for initiating immunomodulatory therapy 1

Factors Requiring Caution

• Bronchiectasis increases susceptibility to respiratory infections, which may be exacerbated by immunomodulatory therapy 1
• The combination of asthma and bronchiectasis represents a more complex airway pathology 1
• Consider prophylactic vaccination against pneumococcal and influenza infections before initiating therapy 1

Alternative Considerations

• If respiratory concerns are significant, TNF inhibitors have longer safety data in patients with respiratory comorbidities 1
• For patients with both psoriatic arthritis and significant skin involvement, IL-17 inhibitors are also recommended and could be considered as an alternative 1

Implementation Plan

• Establish baseline respiratory status with pulmonary function tests 1
• Ensure optimal management of underlying asthma and bronchiectasis before initiating risankizumab 1
• Schedule more frequent follow-up visits during the initial treatment period to monitor for respiratory symptoms 1
• Educate the patient about promptly reporting any increase in respiratory symptoms or sputum production 1
• Consider collaboration between rheumatology and pulmonology for optimal management 1

Conclusion on Risk-Benefit Assessment

• The presence of bronchiectasis, asthma, and past smoking history modifies the risk-benefit assessment but does not contraindicate risankizumab use 1
• The absence of active infection on recent bronchoscopy is reassuring 1
• Close monitoring and a lower threshold for intervention if respiratory symptoms develop is recommended 1