Immunomodulatory or immunosuppressive-induced neuropathies Bill O*, Tsouni P*, Benninger D, Truffert A, Ochsner F, Renard D, Buclin T, Kuntzer T *: co-first authors; email to: thierry.kuntzer@chuv.ch Background and Objective Anti-TNF alpha medications are increasingly used for auto-immune conditions, such as inflammatory bowel disease, multiple sclerosis, inflammatory myopathies and peripheral neuropathies, and arthritis. The long term tolerability and safety of these immunosuppressive therapies in the routine clinical practice remains unclear. The purpose of this work is to show that immune-induced neuropathies (I-induced NP) occur during initial or maintenance treatment. Results Patient #1 # 2 # 3 # 4 #5 Age (y.o.) & Gender 45 f 32 m 52 59 25 Treated disorder Crohn's disease (CD) CD ulcerative colitis kidney recipient spondyl-arthropathy Treatment adalimumab infliximab tacrolimus etanercept Duration of treatment 4 y 6 m 10 m 10 y 6 m after switch Clinical Manifestations Small fiber PN and erythromelalgia Left femoral PN Lewis-Sumner syndrome Late-onset CIDP S1 right radiculomyelitis Nerve conduction studies Prolonged median nerve DML  CMAP amplitude of the left femoral nerve + Proximal conduction block Multifocal sensorymotor conduction blocks Absent SNAPs prolonged DML in 6 nerves Absent right H-reflex Effective Capsaicin (0.025%) Ineffective prednisone acetyl salicylic acid pregabalin surgical decompression 1X IVIG (2g/kg) 4X IVIG 1 PLEX Ineffective Prednisone (worsening of muscle weakness) golimumab High-dose dexamethasone Outcome Pain reduction Recovery (with persistant quadriceps muscle wasting) Improvement Switch to adalimumab after 3 months Almost full recovery Switch to sirolimus Partial recovery S F C MF G A = sensitive = motor Onset type : Acute , Subacute, Chronic onset Methods and Patients During the last 5 years – and among a population of 8,500 patients seen in our neuromuscular outpatient clinic – we have encountered 5 such patients. A 6th patient was excluded by the discovery of a familial basis of the neuropathy. Pattern : Focal, MultiFocal, Generalised Conclusions Our I-induced PNs were surprisingly heterogeneous in their clinical manifestations (onset, pattern, type) and were seen during initial or maintenance therapy periods. No true peripheral nerve toxicity (i.e., dependent on cumulative dose) was identified. Recognition of the I-induced neuropathies has management (targeted immunotherapy) and prognostic (mostly favorable) implications. References Yang et al. Clin rheumatol 2012; Alshekhlee A et al. Muscle Nerve 2010; Richez C et al. Neuroloy 2005; Bouchra et al. Clin Rheumatol 2009; Stubgen et al. J Neurol Sci, 2011; Tristano et al. J Neurol, 2010