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Shirah B, Altwirgi S, Faridoon I, Alghamdi S. Adalimumab-induced central nervous system demyelination in a patient with rheumatoid arthritis. Neuroradiol J 2024; 37:234-236. [PMID: 37125695 PMCID: PMC10973832 DOI: 10.1177/19714009231173102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Adalimumab (Humira) is a human monoclonal antibody that belongs to the tumor necrosis factor (TNF) alpha antagonist class of medications. Central Nervous System (CNS) demyelination is a rare side effect of adalimumab, and only a few cases have been reported in the literature of patients who developed multiple sclerosis or other demyelinating patterns after using adalimumab. In this report, we present a case of CNS demyelination in a patient with rheumatoid arthritis that developed a few months after using adalimumab. Performing brain MRI for asymptomatic individuals prior to initiating anti-TNF alpha agents to exclude a pre-existing demyelinating disease may be worthwhile. Routine brain MRI for monitoring and surveillance may facilitate detecting cases early and avoid the development of permanent neurological disability. Further studies are needed to clarify the neurological safety of anti-TNF alpha agents.
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Affiliation(s)
- Bader Shirah
- Department of Neuroscience, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | | | - Irfan Faridoon
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Saeed Alghamdi
- Department of Neuroscience, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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2
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Li L, Etminan M, Kaplan GG, Tremlett H, Xie H, Aviña-Zubieta JA. Multiple Sclerosis Risk Among Anti-tumor Necrosis Factor Alpha Users: A Methodological Review of Observational Studies Based on Real-world Data. Curr Drug Saf 2024; 19:200-207. [PMID: 37496244 DOI: 10.2174/1574886318666230726162245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/12/2023] [Accepted: 06/27/2023] [Indexed: 07/28/2023]
Abstract
Epidemiologic studies on the risk of multiple sclerosis (MS) or demyelinating events associated with anti-tumor necrosis factor alpha (TNFα) use among patients with rheumatic diseases or inflammatory bowel diseases have shown conflicting results. Causal directed acyclic graphs (cDAGs) are useful tools for understanding the differing results and identifying the structure of potential contributing biases. Most of the available literature on cDAGs uses language that might be unfamiliar to clinicians. This article demonstrates how cDAGs can be used to determine whether there is a confounder, a mediator or collider-stratification bias and when to adjust for them appropriately. We also use a case study to show how to control for potential biases by drawing a cDAG depicting anti-TNFα use and its potential to contribute to MS onset. Finally, we describe potential biases that might have led to contradictory results in previous studies that examined the effect of anti-TNFα and MS, including confounding, confounding by contraindication, and bias due to measurement error. Clinicians and researchers should be cognizant of confounding, confounding by contraindication, and bias due to measurement error when reviewing future studies on the risk of MS or demyelinating events associated with anti-TNFα use. cDAGs are a useful tool for selecting variables and identifying the structure of different biases that can affect the validity of observational studies.
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Affiliation(s)
- Lingyi Li
- Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Mahyar Etminan
- Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Ophthalmology and Visual Sciences, Medicine and Pharmacology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Helen Tremlett
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- The Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada
| | - Hui Xie
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - J Antonio Aviña-Zubieta
- Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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3
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Rojas-Carabali W, Boada-Robayo L, Chacón-Zambrano D, Criollo Porras E, Kerguelén Dumar V, de-la-Torre A. Multiple Sclerosis in a Patient with Intermediate Uveitis and Juvenile Idiopathic Arthritis Treated with Adalimumab: A Case Report. Ocul Immunol Inflamm 2023; 31:1873-1876. [PMID: 36150118 DOI: 10.1080/09273948.2022.2113800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE To report a case of multiple sclerosis (MS) development in a patient with Juvenile Idiopathic Arthritis (JIA) and bilateral intermediate uveitis (IU) treated with Adalimumab. CASE REPORT A 21-year-old Colombian woman diagnosed with JIA and bilateral refractory IU treated with methotrexate and Adalimumab with difficult control of the disease and multiple ocular complications. Eight years after starting Adalimumab, the patient presented paresthesia in the left upper limb. Radiologic findings in the brain and cervical spine MRI confirmed the diagnosis of MS. CONCLUSIONS We reported the first case of MS development in a patient with JIA treated with Adalimumab and the third in a patient with noninfectious uveitis treated with anti-TNFα. It remains uncertain whether MS is secondary to anti-TNFα therapy or is linked to a polyautoimmunity phenomenon.
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Affiliation(s)
- William Rojas-Carabali
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Laura Boada-Robayo
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Daniela Chacón-Zambrano
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | | | - Valentina Kerguelén Dumar
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
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Letarouilly JG, Vermersch P, Flipo RM. Therapeutic consequences in patients with both inflammatory rheumatic diseases and multiple sclerosis. Rheumatology (Oxford) 2023; 62:2352-2359. [PMID: 36440887 DOI: 10.1093/rheumatology/keac665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/19/2022] [Indexed: 07/20/2023] Open
Abstract
Dealing with patients with both multiple sclerosis (MS) and inflammatory rheumatic disorders (IRDs) is not uncommon for a rheumatologist, as there is a statistical association between SpA and MS. As several CNS demyelinating events have been reported in patients treated with TNF inhibitor (TNFi), the pre-existing demyelinating disease was considered a contraindication for TNFi. However, this contraindication is mainly based on a randomized controlled trial in MS and not on large epidemiological studies. According to the last epidemiological studies, TNFi might not be an inducer of MS. Moreover, there are no clear recommendations on the use of the other DMARDs in patients suffering from an IRD and MS. In this review, we summarize the link between MS and IRDs and the impact of DMARDs on MS, especially TNFi. We also look at the impact of disease-modifying drugs for adults with MS and IRDs.
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Affiliation(s)
| | - Patrick Vermersch
- Université de Lille, CHU Lille, INSERM UMR1172 LilNCog, FHU PRECISE, Service de Neurologie, Lille, France
| | - René-Marc Flipo
- Université de Lille, CHU Lille, FHU PRECISE, Service de Rhumatologie, Lille, France
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Li L, Aviña-Zubieta JA, Bernstein CN, Kaplan GG, Tremlett H, Xie H, Peña-Sánchez JN, Marrie RA, Etminan M. Risk of Multiple Sclerosis Among Users of Antitumor Necrosis Factor α in 4 Canadian Provinces: A Population-Based Study. Neurology 2023; 100:e558-e567. [PMID: 36307225 PMCID: PMC9946189 DOI: 10.1212/wnl.0000000000201472] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/09/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Antitumor necrosis factor α (TNFα) agents are a class of biologic drugs used for the treatment of several immune-mediated conditions. An increased risk of multiple sclerosis (MS) with their use has been suggested, but studies have been limited. Relevant population-based epidemiologic data linking anti-TNFα to MS are scarce. The objective was to compare the risk of MS in anti-TNFα users with nonusers among patients with rheumatic disease (RD) or inflammatory bowel disease (IBD). METHODS A nested case-control study was conducted. Population-based health care-linked databases from 4 Canadian provinces were used. All patients with RD or IBD residing within a participating province between January 2000 and March 2018 were identified by validated case definitions. Any anti-TNFα dispensation in the 2 years before the index date (MS onset) was identified. Incident onset MS cases were ascertained using a validated algorithm. Up to 5 controls were matched to each MS case based on birth year ±3 years, disease duration, and health authority (based on region of residence). Conditional logistic regressions were used to calculate the incidence rate ratio (IRR) after adjusting for potential confounders. A meta-analysis was conducted to provide pooled estimates across provinces using random-effects models. RESULTS Among 296,918 patients with RD patients, 462 MS cases (80.1% female, mean [SD] age, 47.4 [14.6] years) were matched with 2,296 controls (59.5% female, mean [SD] age, 47.4 [14.5] years). Exposure to anti-TNFα occurred in 18 MS cases and 42 controls. After adjusting for matching variables, sex, and the Charlson Comorbidity Index, the pooled IRR was 2.05 (95% CI, 1.13-3.72). Among 84,458 patients with IBD, 190 MS cases (69.5% female, mean [SD] age, 44.3 [12.3] years) were matched with 943 controls (54.1% female, mean [SD] age, 44.2 [12.2] years). Exposure to anti-TNFα occurred in 23 MS cases and 98 controls. The pooled adjusted IRR was 1.35 (95% CI, 0.70-2.59). DISCUSSION The use of anti-TNFα was associated with an increased risk of MS compared with nonusers, especially among patients with RD. These findings could help clinicians and patients with RD to make more informed treatment decisions. Further studies are needed to validate these results for patients with IBD.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Mahyar Etminan
- From the Experimental Medicine Program (L.L., J.A.A.-Z., M.E.), Division of Rheumatology (J.A.A.-Z.), Department of Medicine, Division of Neurology (H.T.), Faculty of Medicine, and Departments of Ophthalmology and Visual Sciences (M.E.), Medicine and Pharmacology, University of British Columbia, Vancouver; Arthritis Research Canada (L.L., J.A.A.-Z., H.X.), Vancouver, British Columbia; Departments of Internal Medicine (C.N.B., R.A.M.) and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; Departments of Medicine and Community Health Sciences (G.G.K.), University of Calgary, Alberta; The Djavad Mowafaghian Centre for Brain Health (H.T.), Vancouver, British Columbia; Faculty of Health Sciences (H.X.), Simon Fraser University, Burnaby, British Columbia; and Department of Community Health and Epidemiology (J.-N.P.-S.), College of Medicine, University of Saskatchewan, Saskatoon, Canada.
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Bridge F, Bennett T, Buzzard K. Sixteen syndrome: a rare presentation of central demyelination. BMJ Case Rep 2023; 16:e250440. [PMID: 36627136 PMCID: PMC9835865 DOI: 10.1136/bcr-2022-250440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
This case illustrates two diagnostic challenges for clinicians: the rarely described sixteen syndrome and the relationship between tumour necrosis factor (TNF)-alpha inhibitors and central demyelination. Sixteen syndrome affects horizontal eye movements and the facial nerve bilaterally reflecting a lesion in the posterior pontine tegmentum, adjacent to the fourth ventricle. Given its rarity and complexity of clinical signs, this syndrome risks misdiagnosis and mismanagement. The relationship between TNF-alpha inhibitors and demyelination is a complex issue in which causality is yet to be established. This diagnostic challenge poses a management dilemma for clinicians.
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Affiliation(s)
- Francesca Bridge
- Neurosciences, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
- Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Tim Bennett
- Rheumatology, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Katherine Buzzard
- Neurology, Box Hill Hospital, Box Hill, Victoria, Australia
- Neurosciences, Eastern Health, Monash University, Clayton, Victoria, Australia
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Gu J, Sun J, Zhang Y, Wang X, Fu L, Li L, Wang D, Wang X, Yu L, Han X. Lack of association between TNFA and TNFB polymorphisms and the risk of multiple sclerosis: a meta-analysis from 37 studies. Expert Rev Clin Immunol 2022; 18:1083-1090. [PMID: 35998365 DOI: 10.1080/1744666x.2022.2117160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Epidemiological studies about the association between genetic polymorphisms in TNFA, TNFB, and IFNG and the risk for multiple sclerosis (MS) have been performed extensively. However, the results are inconclusive. The purpose of this meta-analysis was to evaluate the contribution of the polymorphisms in TNFA, TNFB, and IFNG to the susceptibility of MS. METHODS The PubMed, Web of Science, and China National Knowledge Infrastructure databases were searched to identify relevant studies up to October 2021. A meta-analysis was performed and pooled odds ratios (OR) and confidence intervals (CI) were computed using fixed or random effects models. RESULTS A marginally significant association of the IFNG +874AT genotype with high risk of MS was observed in a heterozygous comparison (OR = 1.51, 95% CI, 1.02-2.23). However, no significant association between the TNFA (-308G/A, -238G/A, and -376G/A) and TNFB +252A/G polymorphisms and MS risk was observed both in overall analysis and in subgroup analysis. CONCLUSION This meta-analysis provides evidence that the TNFA (-308G/A, -238G/A, and -376G/A) and TNFB +252A/G polymorphisms were not risk factors for the occurrence of MS. Further studies with larger samples are necessary to reach the concise results about the contribution of other polymorphisms to the risk of MS.
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Affiliation(s)
- Jiebing Gu
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Jing Sun
- Department of Dermatology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Yingyu Zhang
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Xiaoshuang Wang
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Lingling Fu
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Linfang Li
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Di Wang
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Xiuting Wang
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Le Yu
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
| | - Xuemei Han
- No. 1 Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130031, P.R.China
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Redenbaugh V, Flanagan EP, Floris V, Zara P, Bhatti MT, Sanchez F, Koster M, Mariotto S, Pittock SJ, Chen JJ, Cauli A, Solla P, Sechi E. Exposure to TNF inhibitors is rare at MOGAD presentation. J Neurol Sci 2021; 432:120044. [PMID: 34728073 DOI: 10.1016/j.jns.2021.120044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Vyanka Redenbaugh
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Valentina Floris
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy; Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Pietro Zara
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy; Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - M Tariq Bhatti
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Francisco Sanchez
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Matthew Koster
- Department of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - John J Chen
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Alberto Cauli
- Rheumatology Unit, Department of Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Paolo Solla
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy.
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