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Treating Leukocytoclastic Vasculitis Associated with Etanercept Therapy. Is It Necessary to Stop Etanercept?: Dr. Mohan replies To the Editor: In response to Juan, et al, review of available US Food and Drug Administration Adverse Events Reporting System data revealed there were 4 patients in the series that were reportedly continued on etanercept. Outcomes regarding 2 of them are unknown. One patient improved on low-ering the dosing to once a week and worsened again on increasing the dosage to twice a week. The other patient improved partially on discontin-uation, but rechallenge one month later did not cause any worsening. Infliximab was continued in one patient with premedication with antihist-amines and steroids, who was reported to be slowly improving. This sug-gests there may be more than one mechanism responsible for development of leukocytoclastic vasculitis (LV). Three patients (2 on etanercept and one on infliximab) were taking concomitant leflunomide when they developed LV. One patient taking etanercept was not rechallenged, while the other had a positive rechallenge despite being on leflunomide. The patient on infliximab developed LV 4 days after the first infusion. The second infusion, which was due in 2 weeks, was held while awaiting resolution of the skin lesions. The next infusion was given 6 weeks after the first, and no recurrence of skin lesions was noted, indicating a negative rechallenge. This suggests that in these patients, leflunomide was not consistently effective against the develop-ment of drug-associated LV. The response of Juan's patient to leflunomide, however, adds to the possible list of interventions that one can attempt with a patient who has had a good therapeutic response to tumor necrosis factor (TNF) blockade but has unfortunately developed drug-associated LV. Other interventions include cautious rechallenge after resolution of skin lesions, premedication with antihistamines and corticosteroids, switching to another TNF block-ing agent, and reducing the dosage. NIVEDITHA MOHAN, MBBS, Avera Research Institute, 2020 S. Norton Avenue, Sioux Falls, South Dakota 57108, USA. |