Cardiovascular risk in rheumatoid arthritis patients treated with targeted synthetic and biological disease-modifying antirheumatic drugs: A multi-centre cohort study

Comparative safety of biologic and targeted synthetic disease-modifying anti-rheumatic drugs for cardiovascular outcomes in rheumatoid arthritis

OBJECTIVES

To assess the comparative safety of TNF inhibitor (TNFi), non-TNFi, and Janus kinase inhibitor (JAKi) biologic or targeted synthetic DMARD (b/tsDMARD) in patients with RA for the risk of major adverse cardiovascular events (MACE) using US administrative claims data.

METHODS

We performed a cohort study using Merative™ Marketscan® Research Databases (2012-2021) of individuals aged 18-64 years with RA initiating b/tsDMARD treatment. We used Cox proportional hazard models to estimate hazard ratios (HR) and 95% CI for developing MACE within 2 years of b/tsDMARD initiation, adjusting for potential confounders.

RESULTS

We included a total of 34 375 treatment exposures: 71% TNFi, 10% JAKi, 8% abatacept, 5% rituximab and 5% IL-6i. Most individuals were female (77-84%) with a median (interquartile range) of 50 (42, 56) years. Rituximab had the highest incidence rate of MACE (196/10 000 person-years; 95% CI 126, 291), followed by IL-6i (111/10 000 person-years; 95% CI 57, 193). Multivariable analyses showed non-statistically significantly higher MACE risk with rituximab (HR 1.5; 95% CI 0.9, 2.4) and IL-6i (HR 1.3; 95% CI 0.7, 2.4) exposures but no increased risk with JAKi relative to TNFi use.

CONCLUSION

In this large nationwide study, rituximab and IL-6i users had numerically higher, but not statistically significant, MACE risk. Our data support the safety of b/tsDMARD use for RA treatment. This study was limited by short follow-up time and confounding by indication; further studies that can overcome these limitations are needed.

Safety of Janus kinase inhibitors in immune-mediated inflammatory diseases - a systematic literature review informing the 2024 update of an international expert consensus statement

OBJECTIVES

This systematic literature review (SLR) on safety outcomes was performed to inform the 2024 update of the expert consensus statement on the treatment of immune-mediated inflammatory diseases (IMIDs) with Janus kinase inhibitors (JAKi).

METHODS

An update of the 2019 SLR was performed in MEDLINE, Embase, and the Cochrane Library. For safety, randomised, placebo-controlled or active-controlled trials on all JAKi investigated in IMIDs, long-term extension (LTE) studies, pooled trial data analyses, and cohort and claims studies were included.

RESULTS

We screened 13,905 records, of which 209 were finally included. Three safety trials and 13 post hoc analyses, 83 efficacy randomised controlled trials (RCTs) with adequate safety reporting, 56 integrated safety analyses and LTE of RCTs, 20 additional conference abstracts on RCT data, as well as 37 real-world cohort studies were presented to the task force. Safety profiles of JAKi were overall consistent across compounds and indications, but impacts of patient profiles, treatment dosing, and other cofactors like background medications on drug safety could be observed. Furthermore, differential effects of variously selective JAKi on distinct adverse events of special interest (AESI) and laboratory outcomes were discerned.

CONCLUSION

A substantial amount of literature was published on JAKi safety since 2019. A comprehensive overview of these data supports the optimal use of JAKi in patients with IMIDs, by consideration and balance of their benefits as well as risks in every patient.

Frailty and cardiovascular safety of JAK inhibitors versus TNF inhibitors in rheumatoid arthritis: a real-world comparative study of drug effects and patient profiles

Objective

The aim of this study was to comparatively assess the risk of cardiovascular events (CVEs) in rheumatoid arthritis (RA) patients treated with Janus kinase inhibitors (JAKis) or tumor necrosis factor inhibitors (TNFis) and to explore the interactions with patient profiles [including age, baseline cardiovascular (CV) risk, and frailty, which is a state of decreased physiological reserve, assessed using a validated frailty index (FI) for healthcare administrative databases (AHDs)].

Methods

This retrospective study was based on AHDs of the Lombardy region, Italy (from 1st January 2020 to 31st December 2023). Cox regression models, both crude and adjusted, were applied to estimate the association between treatments and outcomes [CVEs, major adverse cardiovascular events (MACEs), and thromboembolic events (TEs)]. We tested the interaction between the drug treatment and the regulatory agency prescription rule changes [before or after 06th July 2021, the date of the first European Medicine Association (EMA) pronouncement on tofacitinib safety] or patient profiles.

Results

We identified 7,541 therapeutic courses in 5,563 patients: 2,343 started as TNFi users, 1,443 as JAKi users, and 1,777 started with other drugs (1,459 days of follow-up). The crude incidence rates (IRs) for new CVEs were 16.6 [95% confidence intervals (95% CI): 12.8-21.2] and 18.6 (95% CI: 14.2-23.9) per 1,000 person-years (PYs) for TNFi and JAKi users, respectively. Exposure to JAKis was not associated with a significantly increased risk of CVEs [adjusted hazard ratio (HR): 0.92; 95% CI: 0.64-1.32], MACEs (adjusted HR: 0.71; 95% CI: 0.37-1.33), or TEs (adjusted HR: 1.53; 95% CI: 0.65-3.65) compared to TNFis. Each 0.1-point increment of the FI significantly increased the HR for new CVEs (HR: 1.80; 95% CI: 1.48-2.19), MACEs (HR: 1.66; 95% CI: 1.10-2.51), and TEs (HR: 1.69; 95% CI: 1.03-2.78). When assessing the interaction between the period of drug delivery and the treatment with JAKis on the risk of new CVEs, no significant interaction was observed (p = 0.838), while the interaction was statistically significant for baseline CV risk (p = 0.007).

Conclusion

RA patients treated with JAKis in real-world settings have a risk of developing CVEs no higher than those of TNFi users, but potential signals remain for TEs, even if the sample was not sufficiently powered. Patient profiles, particularly the frailty, have a more substantial impact on the risk of CVEs than the specific disease-modifying anti-rheumatic drug (DMARD) choice.

Achievement of treatment targets and maintenance of response with upadacitinib in patients with moderate-to-severe rheumatoid arthritis in real-world practice: 1-year outcomes from the UPHOLD observational study

BACKGROUND

Upadacitinib (UPA), an oral Janus kinase inhibitor, has shown efficacy with an acceptable safety profile in rheumatoid arthritis (RA) clinical trials.

OBJECTIVE

To assess the real-world effectiveness and safety of UPA in adults with moderate-to-severe RA in the UPHOLD observational study.

METHODS

Co-primary endpoints were: (i) proportion of patients achieving disease activity score in 28 joints using C-reactive protein (DAS28[CRP]) remission (< 2.6) at 6 months; and (ii) proportion of those patients maintaining remission at 12 months. Additional analyses included proportions of patients achieving and maintaining DAS28(CRP) low disease activity (LDA; ≤ 3.2), other composite measures of disease activity, and subgroup analyses by therapy strategy and prior treatment. Treatment-emergent adverse events (TEAEs) in the full analysis set (FAS; patients receiving ≥ 1 UPA dose) were reported through August 10, 2023. Co-primary and selected secondary endpoints were analyzed by modified non-responder imputation (mNRI) in modified (m)FAS1 (FAS patients who completed 6 months of treatment and had DAS28[CRP] data available, and those who discontinued before 6 months) and mFAS2 (mFAS1 patients who achieved remission at 6 months, completed 12 months of treatment, and had DAS28[CRP] data available, and those who discontinued between 6 and 12 months); and as observed (AO) in patients with non-missing data.

RESULTS

Of 1719 participants, 1717 were enrolled; 1701 comprised the FAS. Overall, 400/1719 (23.3%) patients discontinued before 12 months. Of mFAS1 patients, 499 (mNRI: 499/1074 [46.5%]; AO: 499/902 [55.3%]) achieved DAS28(CRP) remission at 6 months; of mFAS2 patients, 269 (mNRI: 269/340 [79.1%]; AO: 269/317 [84.9%]) maintained remission at 12 months. DAS28(CRP) remission or LDA rates were consistent regardless of whether UPA was initiated and maintained as monotherapy or combination therapy. Similar responses were observed across prior treatment subgroups. Among selected TEAEs of special interest, herpes zoster and serious infection occurred at 3.12 and 2.62 events/100 patient-years, respectively. No new safety signals were identified.

CONCLUSIONS

UPA demonstrated real-world effectiveness in moderate-to-severe RA, with approximately half of patients achieving DAS28(CRP) remission at 6 months and most maintaining remission through 12 months. The real-world benefit-risk profile of UPA remains favorable and is consistent with phase 3 clinical trial data.

TRIAL REGISTRATION

NCT04497597.

Risk of major adverse cardiovascular events following targeted therapy in patients with rheumatoid arthritis: a real-world analysis stratified by cardiovascular risk

OBJECTIVE

To assess the risk of major adverse cardiovascular events (MACEs) associated with Janus kinase inhibitors (JAKi) compared to tumour necrosis factor inhibitors (TNFi) in rheumatoid arthritis (RA).

METHODS

Using the Korean nationwide claims database, we identified patients with RA prescribed JAKi or TNFi between 2015 and 2019. Patients were stratified into two groups based on cardiovascular (CV) risk and matched within each group using propensity score matching at a ratio of up to 1:4. Follow-up continued until MACE, death, or treatment discontinuation. Hazard ratios with 95 % confidence intervals were calculated using the Cox proportional hazards model. Additionally, MACE risk was analyzed separately in patients with and without a history of cardiovascular disease (Hx.CVD).

RESULTS

A total of 7575 patients prescribed either JAKi or TNFi were included. After propensity score matching, the hazard ratio for MACEs comparing JAKi to TNFi was 0.77 (95 % confidence interval 0.45-1.34) in the high CV risk group. No significant differences in MACEs were observed between JAKi and TNFi users across the low CV risk group, as well as Hx.CVD and non-Hx.CVD groups. Subgroup and sensitivity analyses showed no statistically significant differences in the risk of individual MACE components, such as myocardial infarction, stroke, or heart failure.

CONCLUSION

No significant differences in the risk of MACEs were observed between JAKi and TNFi users across various CV risk groups and in those with or without Hx.CVD. Subgroup and sensitivity analyses supported these findings, showing no elevated risks for individual MACE components.

Major adverse cardiovascular events or venous thromboembolism in patients with rheumatoid arthritis initiating biological or targeted synthetic disease-modifying antirheumatic drugs: a nationwide, population-based cohort study

Background

Rheumatoid arthritis (RA) is complicated by a high risk of cardiovascular disease and requires the initiation of biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for persistently active disease despite first-line therapies. The influence of b/tsDMARDs, especially tsDMARDs, on cardiovascular risk in Taiwanese patients with RA remains unclear.

Objectives

To compare the risk of major cardiovascular adverse events (MACEs) or venous thromboembolism (VTE) amongst RA patients initiating approved b/tsDMARDs for up to 5 years.

Design

A nationwide, population-based, retrospective cohort study.

Methods

Using Taiwan National Health Insurance (NHI) Research Database, we identified patients with RA initiating NHI-reimbursed b/tsDMARDs indicated for RA between 2001 and 2020. Study outcomes were newly developed MACEs or VTE within 5 years of the first b/tsDMARD initiation. Time-dependent Cox regression analysis was performed to determine the association between b/tsDMARDs and MACEs or VTE and independently associated or protective factors. Subgroup analyses by age at b/tsDMARD initiation and cardiovascular risk levels, as well as sensitivity analyses of b/tsDMARD initiation after 2012, were performed.

Results

We enrolled 12,332 adults with RA initiating the first b/tsDMARD during pre-determined period. The incidence rates of MACE and VTE were 894 and 283 per 100,000 person-years, respectively. After adjustment, other b/tsDMARDs were not associated with a higher risk of MACEs or VTE than tumour necrosis factor inhibitors (TNFis) up to 5 years after initiation. Subgroup analyses by age at b/tsDMARD initiation and cardiovascular risk levels revealed consistent findings. Factors associated with or protective against MACEs or VTE were identified.

Conclusion

No non-TNFi b/tsDMARD had a higher risk of MACEs or VTE than TNFis up to 5 years after initiation amongst patients with RA, and this remained consistent for those initiating their b/tsDMARD at age 65 years and older or with high cardiovascular risk.

JAK inhibitor selectivity: new opportunities, better drugs?

Cytokines function as communication tools of the immune system, serving critical functions in many biological responses and shaping the immune response. When cytokine production or their biological activity goes awry, the homeostatic balance of the immune response is altered, leading to the development of several pathologies such as autoimmune and inflammatory disorders. Cytokines bind to specific receptors on cells, triggering the activation of intracellular enzymes known as Janus kinases (JAKs). The JAK family comprises four members, JAK1, JAK2, JAK3 and tyrosine kinase 2, which are critical for intracellular cytokine signalling. Since the mid-2010s multiple JAK inhibitors have been approved for inflammatory and haematological indications. Currently, approved JAK inhibitors have demonstrated clinical efficacy; however, improved selectivity for specific JAKs is likely to enhance safety profiles, and different strategies have been used to accomplish enhanced JAK selectivity. In this update, we discuss the background of JAK inhibitors, current approved indications and adverse effects, along with new developments in this field. We address the issue of JAK selectivity and its relevance in terms of efficacy, and describe new modalities of JAK targeting, as well as new aspects of JAK inhibitor action.

Comparative cardiovascular safety with janus kinase inhibitors and biological disease-modifying antirheumatic drugs as used in clinical practice: an observational cohort study from Sweden in patients with rheumatoid arthritis

OBJECTIVES

To compare the incidence of cardiovascular (CV) events in rheumatoid arthritis (RA) treated with janus kinase inhibitors (JAKi), tumour necrosis factor inhibitors (TNFi), or other biological disease-modifying antirheumatic drugs (bDMARDs), in clinical practice, and to contextualise these findings by comparing to the Swedish RA population and general population at large.

METHODS

Patients with RA initiating JAKi, TNFi and non-TNFi bDMARDs were identified in the Swedish Rheumatology Quality Register between 2016 and 2021. Through linkages to national registers, a cohort of patients with RA, general population comparators, as well as covariates and incident major acute CV event (MACE, including myocardial infarction, stroke and fatal CV events) were identified until 2022. Crude and age-sex standardised rates were calculated and HRs estimated from multivariable Cox regression models using TNFi as reference.

RESULTS

We identified 13 492 patients with RA initiating a JAKi, non-TNFi bDMARD or TNFi treatment. Among 3037 JAKi-initiators, 59 MACE events were observed. The age-sex standardised rates for MACE were similar in the JAKi (0.88 per 100 person years) and TNFi (0.91) cohorts. Fully adjusted models showed no increased rate of MACE with JAKi (HR=0.71, 95% CI 0.51 to 0.99), or non-TNFi bDMARD (HR=0.98; 95% CI 0.78 to 1.23) in comparison to TNFi. We found no evidence that this HR changed over time since treatment initiation. In a CV-enriched subset, we observed higher rates but similar HRs.

CONCLUSIONS

As used in present clinical practice in Sweden, we found no evidence that CV risk is higher with JAKis than TNFis in RA.

Examining the Safety Profile of Janus Kinase (JAK) Inhibitors in the Management of Immune-Mediated Diseases: A Comprehensive Review

Janus kinase (JAK) inhibitors have heralded a paradigm shift in the management of immune-mediated diseases. While their efficacy is well-established, the safety concerns associated with these agents, particularly regarding thromboembolic events (TE), remain a focus of extensive research and clinical scrutiny. This comprehensive literature review embarks on an exploration of the multifaceted landscape of JAK inhibitors, providing insights into their safety profiles across diverse immune-mediated diseases. The introduction highlights the transformative influence of JAK inhibitors in the treatment of immune-mediated diseases. Historically, the therapeutic arsenal for these conditions included corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biologics. The advent of JAK inhibitors has revolutionized this landscape, although concerns about their safety persist. This review strives to comprehensively evaluate their safety, amalgamating knowledge from multiple studies and trials. The subsequent sections delve into the safety of specific JAK inhibitors in the context of rheumatoid arthritis, inflammatory bowel diseases, and dermatologic conditions and their associations with venous thromboembolism. The evolving understanding of TE risk, particularly the intricate relationship between these agents and immune-mediated diseases, is meticulously unravelled. The concluding remarks underscore the dynamic nature of TE risk assessment with regard to immune-mediated diseases involving JAK inhibitors. It underscores that risk assessment is multifactorial, influenced not only by the choice of JAK inhibitor but also by the nuances of the underlying immune-mediated disease and the unique patient characteristics. This review offers a holistic perspective on TE risks associated with JAK inhibitors and contributes to the ongoing dialogue regarding their safety in the realm of immune-mediated diseases.

Cardiovascular risk of Janus kinase inhibitors compared with biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis without underlying cardiovascular diseases: a nationwide cohort study

Objectives: Despite the ethnic differences in cardiovascular (CV) risks and recent increase in the prescription of Janus kinase (JAK) inhibitors, limited evidence is available for their CV outcomes in Asian patients with rheumatoid arthritis (RA). We aimed to compare the major adverse CV events (MACEs) of JAK inhibitors to those of biologic disease-modifying antirheumatic drugs (bDMARDs) in Korean patients with RA without baseline CV disease (CVD). Methods: In a nationwide retrospective cohort study, patients newly diagnosed with RA without a history of CVD between 2013 and 2018 were identified using the National Health Insurance Service database. The cohort was followed up until the end of 2019 for the development of MACEs. Hazard ratios (HRs) for MACEs such as myocardial infarction, stroke, coronary revascularization, or all-cause death, were estimated using Cox proportional hazard regression in a propensity score-matched cohort. Results: In total, 4,230 matched patients with RA were included (846 JAK inhibitor users and 3,384 bDMARD users). The crude incidence rate (95% confidence intervals, CI) per 100 patient-years for MACEs was 0.83 (0.31-1.81) and 0.74 (0.53-1.02) in the JAK inhibitor and bDMARD groups, respectively. The risk of MACEs was not significantly different between JAK inhibitor and bDMARD users with an adjusted HR (95% CI) of 1.28 (0.53-3.11). There were no significant differences in the risk of MACEs between JAK inhibitors and bDMARDs in each subgroup according to the types of bDMARDs, age, sex, Charlson comorbidity index score, and comorbidities. Conclusion: Compared to bDMARDs, JAK inhibitors were not associated with the occurrence of MACEs in Korean patients with RA without a history of CVD.