Development of Nephrotic Syndrome in a Patient with Rheumatoid Arthritis Treated with Certolizumab

To the Editor: Tumor necrosis factor-α (TNF-α) inhibitors have become widely accepted and are vital in the treatment of rheumatoid arthritis (RA) and other autoimmune inflammatory diseases1. Their target, TNF-α, promotes inflammation through a variety of mechanisms, including cytokine and chemokine expression, and suppression of regulatory T cells2. Although an important therapy for many inflammatory diseases, TNF-α inhibitors may contribute to serious adverse effects, including infection, heart failure, and hematologic and nervous system disorders1. Here we describe the first documented case, to our knowledge, of nephrotic syndrome with biopsy-proven membranous glomerulonephritis (GN) due to certolizumab in an individual with RA. A 63-year-old female with nodular, erosive, seropositive RA for over 15 years with suboptimal control with hydroxychloroquine (HCQ) monotherapy and previous intolerance to methotrexate presented to the clinic for a second opinion. Her rheumatoid factor was 95 IU/ml and anti-citrullinated protein antibody was > 250. Given her active inflammatory disease with a 28-joint Disease Activity Score (DAS28) of 5.89, we began treatment with adalimumab (ADA). She responded well initially, but effectiveness waned over 12 months with intermittent discontinuation … Address correspondence to Dr. R. Butendieck, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA. E-mail: Butendieck.Ronald{at}mayo.edu