Unstable diabetes in a patient receiving anti-TNF- for rheumatoid arthritis

S ir , Tumour necrosis factor-α (TNF-α) is a cytokine well-recognized as having a significant role in the inflammatory process. Recent advances have led to the production of drugs that inhibit the action of TNF-α, producing significant improvement in the control of rheumatic diseases [ 1 ]. TNF-α may also play a role in other physiological processes. Prolonged administration of anti-TNF-α drugs is increasingly common in the treatment of rheumatic disease and also inflammatory bowel disease. Here we report on a case of an individual whose diabetes became unstable following the administration of anti-TNF drugs. Our case is a 55-yr-old female who has had type 1 diabetes since the age of 30. Aged 33, she developed rheumatoid arthritis. Having failed a number of disease-modifying anti-rheumatic drugs (DMARDs), she was commenced on etanercept (25 mg twice weekly) in April 2003 (DAS = 7.06). This led to significant improvement in her joints immediately. Having previously had stable diabetes, within 3 weeks of commencing the drug, she noticed that her blood sugars were erratic. She had a severe hypoglycaemic attack without warning, followed further by one more a few days later. After urgent clinical review, the etanercept was stopped and her glycaemic control stabilized.