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Clinical Image
A 61-year-old male patient with seropositive, ACPA-positive, erosive rheumatoid arthritis (RA)
presented with a painful, blue-livid discoloration of his right index finger. Three weeks prior, due to
worsening RA-symptoms, RA-therapy was changed from tocilizumab to tofacitinib. Arteriography
showed a significant hypovascularization, oscillography a pathologic pattern. Angiological,
hematological, cardiac and rheumatological workup demonstrated no significant findings but
atherosclerotic changes including the right radial artery. In conclusion the blue-finger-syndrome
can be interpreted as result of atherosclerotic changes, as a potential unexpected adverse event
to tofacitinib or as a combination of both (Figure 1). Tofacitinib was permanently discontinued;
iloprost and enoxaparin were initiated followed by phenprocoumon, which in the further course
was replaced by acetylsalicylic acid. This resulted in rapid improvement of the symptoms. During a
one year follow-up no additional vascular event was observed.
The blue-finger-syndrome results from blockage, usually thromboembolic or traumatic, of
smaller blood vessels. Consequently, search for thromboembolic sources is required. Further causes
include antiphospholipid-antibody-syndrome, connective-tissue-disease or vasculitis. To our
knowledge, the blue-finger-syndrome has not yet been described under tofacitinib-therapy. In this
patient an increase of LDL-cholesterol has been observed subsequent to initiation of tofacitinib.
Therefore Atorvastatin was started during follow-up. An increase of cholesterol in association
with tofacitinib-therapy [1,2] is reported not to augment the risk of cardiovascular events [1,3,4].
In general, the cardiovascular safety profile of tofacitinib is similar to other biological diseasemodifying
anti-rheumatic drugs [5]. Nonetheless, a drug-associated cause should be discussed.