Adverse events of tumor necrosis factor alpha inhibitors for the treatment of ankylosing spondylitis: A meta-analysis of randomized, placebo-controlled trials

Biomarkers for successful tapering of a tumor necrosis factor inhibitor in patients with radiographic axial spondyloarthritis: A pilot study

Background

Tumor necrosis factor inhibitors are the most widely used biological disease-modifying antirheumatic drugs for radiographic axial spondyloarthritis. After achieving remission with tumor necrosis factor inhibitor treatment, experts recommend tapering tumor necrosis factor inhibitor. However, biomarkers for successful tumor necrosis factor inhibitor tapering in radiographic axial spondyloarthritis have not been identified.

Objectives

To identify biomarkers associated with successful tumor necrosis factor inhibitor tapering in patients with radiographic axial spondyloarthritis.

Design

We prospectively collected blood samples from radiographic axial spondyloarthritis patients at single tertiary hospital.

Methods

Patients with radiographic axial spondyloarthritis who achieved remission (axial spondyloarthritis disease activity score < 1.3) after treatment with tumor necrosis factor inhibitor were enrolled. Baseline demographics, medication history, and laboratory data were collected when the tumor necrosis factor inhibitor dose was tapered. The percentage of helper T cell subtypes (Th1/Th2/Th17/Th22) in peripheral blood, and serum levels of tumor necrosis factor-α, interleukin-12, IL-17A, IL-22, IL-23, interferon (IFN)-γ, soluble CD14, and zonulin, were measured. Patients were assigned to tumor necrosis factor inhibitor tapering success (axial spondyloarthritis disease activity score < 2.1) or failure (axial spondyloarthritis disease activity score ⩾ 2.1) groups according to disease activity (assessed at 12 weeks posttumor necrosis factor inhibitor tapering).

Results

Twenty radiographic axial spondyloarthritis patients were enrolled (median age, 31.0 years; 65% males). Most (80%) were positive for human leukocyte antigen-B27. The change of axial spondyloarthritis disease activity score in the tumor necrosis factor inhibitor-tapering failure group was 1.36, while that in the tumor necrosis factor inhibitor-tapering success group was 0.07. The percentage of Th1 and Th17 cells was significantly lower, and that of Th2 cells higher, in the tumor necrosis factor inhibitor-tapering success group. In addition, serum levels of IL-12, IL-17A, IL-22, IFN-γ, tumor necrosis factor-α, zonulin, and soluble CD14 were significantly lower in the tumor necrosis factor inhibitor-tapering success group.

Conclusion

Patients with radiographic axial spondyloarthritis who achieve successful tumor necrosis factor inhibitor tapering had lower percentages of Th1 and Th17 cells, a higher percentage of Th2 cells, and lower serum levels of IL-12, IL-17A, IL-22, IFN-γ, tumor necrosis factor-α, zonulin, and soluble CD14 at the time of tumor necrosis factor inhibitor tapering. These findings may help to identify patients with radiographic axial spondyloarthritis for whom tumor necrosis factor inhibitor tapering is appropriate.

Cardiovascular Adverse Events Associated with Tumor Necrosis Factor-Alpha Inhibitors: A Real-World Pharmacovigilance Analysis

AIM

Evidence regarding the association between various tumor necrosis factor-α (TNF-α) inhibitors and cardiovascular adverse events (AEs) is both limited and contradictory.

METHODS

A retrospective pharmacovigilance study was conducted using the FDA Adverse Event Reporting System (FAERS) database. Cardiovascular AEs associated with TNF-α inhibitors (adalimumab, infliximab, etanercept, golimumab, and certolizumab) were evaluated using a disproportionality analysis. To reduce potential confounders, adjusted ROR and subgroup analyses were performed.

RESULTS

After excluding duplicates, 9,817 cardiovascular reports were associated with the five TNF-α inhibitors. Only adalimumab had positive signals for myocardial infarction (ROR=1.58, 95%CI=1.51-1.64) and arterial thrombosis (ROR=1.54, 95%CI=1.49-1.58). The remaining four TNF-α inhibitors did not show a risk association with any type of cardiovascular event. Further analyses of specific indication subgroups and after adjusting for any confounding factors demonstrated that adalimumab was still significantly associated with cardiovascular events, especially in patients with psoriasis (adjusted ROR=2.16, 95%CI=1.95-2.39).

CONCLUSIONS

This study revealed that adalimumab was the only TNF-α inhibitor associated with an elevated risk of thrombotic cardiovascular AEs, whereas the other four TNF-α inhibitors did not show any risk effect. However, given the limitations of such pharmacovigilance studies, it is necessary to validate these findings in prospective studies in the future.

Factors associated with cause-specific discontinuation of long-term anti-tumor necrosis factor agent use in patients with ankylosing spondylitis: a retrospective cohort study

OBJECT

To investigate the factors associated with cause-specific discontinuation of long-term anti-tumor necrosis factor (TNF) agent use in patients with ankylosing spondylitis (AS).

METHODS

AS patients who initiated first-line anti-TNF treatment between 2004 and 2018 and continued treatment for at least two years were enrolled in the study. Enrolled patients were observed until the last visit, discontinuation of treatment, or September 2022. Reasons for discontinuation of the first-line anti-TNF agent were categorized into the following: (1) clinical remission, (2) loss of efficacy, (3) adverse events, and (4) other reasons including loss to follow-up, cost, or reimbursement issues. A cumulative incidence function curve was used to visualize the cumulative failure rates over time for each specific reason. Univariable and multivariable cause-specific hazard models were utilized to identify factors associated with cause-specific discontinuation of the first-line anti-TNF agent.

RESULTS

A total of 429 AS patients was included in the study, with 121 treated with adalimumab (ADA), 176 with etanercept (ETN), 89 with infliximab (INF), and 43 with golimumab (GLM). The median overall survival on the first-line anti-TNF agent was 10.6 (7.9-14.5) years. Among the patients, 103 (24.0%) discontinued treatment, with 36 (34.9%) due to inefficacy, 31 (30.1%) due to clinical remission, 15 (14.6%) due to adverse events, and 21 (20.4%) due to other reasons. Patients treated with ETN had a lower risk of discontinuation due to clinical remission compared to those receiving ADA (hazard ratio [HR] 0.45 [0.21-0.99], P = 0.048). Higher baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; HR 1.31 [1.04-1.65], P = 0.023) and INF use were linked to a higher risk of treatment discontinuation for inefficacy compared to ADA use (HR 4.53 [1.45-14.16], P = 0.009). Older age was related to an increased risk of discontinuation due to infection-related adverse events (HR 1.07 [1.02-1.12], P = 0.005), and current smoking was a risk factor for discontinuation due to other reasons (HR 6.22 [1.82-21.28], P = 0.004).

CONCLUSION

AS patients on their first anti-TNF treatment for at least two years demonstrated a favorable long-term treatment retention rate, with a 24.0% discontinuation rate over a 10.6-year overall survival period. The predictors for discontinuation varied by causes, underscoring the complexity of treatment response and the importance of personalized approaches to treatment management.

Treatment patterns and factors associated with discontinuation of monoclonal antibodies

Background

Biological agents have revolutionized care in specialties such as oncology, immunology, infectious diseases, and genetic disorders, offering targeted actions on specific molecules or select immune cells. Monoclonal antibodies, known for their high specificity and precision, represent one of the most significant and rapidly expanding categories of these agents. Understanding the drug utilization patterns of monoclonal antibodies is crucial to ensure their optimal use, especially given their high cost and potential adverse effects.

Methods

This analytical cross-sectional study was conducted in a secondary hospital in the United Arab Emirates. Patients of either gender receiving monoclonal antibodies at the study site were included. Treatment patterns, utilization, and factors associated with the discontinuation of monoclonal antibodies were assessed.

Results

Hyperlipidemia (136, 39.1%) was the most common indication for monoclonal antibodies, followed by prophylaxis of respiratory syncytial virus infection in congenital heart disease (104, 29.9%) and osteoporosis (42, 12.1%). Evolocumab was the most commonly prescribed monoclonal antibody (135, 38.8%), followed by palivizumab (104, 29.9%), and dupilumab (38, 10.9%). The majority of monoclonal antibodies demonstrated a prescribed daily dose to defined daily dose ratio of 1.0, reflecting their appropriate utilization. One hundred twenty-nine patients (37.0%) discontinued their treatment during the study. Patient's level of education (OR: 0.416, 95% CI: 0.183-0.943, p = 0.036), BMI (OR: 2.358, 95% CI: 1.164-4.777, p = 0.017), number of concomitant medications (OR: 2.457, 95% CI: 1.202-5.025, p = 0.014), and treatment duration (OR: 9.180, 95% CI: 4.909-17.165, p < 0.001) were identified as predictors of discontinuation of monoclonal antibodies.

Conclusion

This study represents the first comprehensive investigation in the United Arab Emirates focused on treatment patterns, utilization, and discontinuation of monoclonal antibodies among the local population. Monoclonal antibodies were prescribed for the management of a wide range of clinical conditions. The study reports appropriate utilization of most monoclonal antibodies and identifies factors such as patient education level, BMI, concomitant medications, and treatment duration as independent predictors of monoclonal antibody treatment discontinuation.

Biologics Versus JAK Inhibitors. Part II: Risk of Infections. A Narrative Review

INTRODUCTION

The risk of infections associated with biological drugs (BD) and Janus kinase inhibitors (JAKi) has been extensively explored in the literature. However, there is a dearth of studies that evaluate both pharmacological groups together and, furthermore, compare them. Here, we review the risk of infections associated with BD and JAKi used in dermatology.

METHODS

A narrative review was performed. All relevant articles evaluating the risk of infection and opportunistic infections with BD and JAKi between January 2010 and February 2024 were selected.

RESULTS

Overall, the incidence of infections, serious infections, and opportunistic infections associated with BD and JAKi is low, but higher than in the general population. JAKi approved for dermatological disorders (abrocitinib, baricitinib, deucravacitinib, upadacitinib, ritlecitinib, and topical ruxolitinib) have been shown to be safe, and present a low rate of infections. We found an elevated risk, especially with anti-tumor necrosis factor (anti-TNF) agents, rituximab, and JAKi (particularly tofacitinib at high doses). Specific associations with infections include tuberculosis and tuberculosis reactivation with anti-TNF agents and tocilizumab; candidiasis with anti-interleukin (IL) 17 agents; hepatitis B virus reactivation with rituximab, anti-TNF, and JAKi; and herpes simplex and herpes zoster infections with JAKi (especially tofacitinib and upadacitinib at high doses). The incidence of infections with ustekinumab and anti-IL-23 was very low. Anti-IL-1, nemolizumab, tralokinumab, and omalizumab were not associated with an increased risk of infections. Dupilumab could decrease the incidence of cutaneous infections.

CONCLUSIONS

Anti-TNF agents, rituximab, and JAKi (particularly tofacitinib) can increase the risk of infections. Close monitoring of patients undergoing these therapies is recommended. Prospective studies with long-term follow-up are needed to comparatively evaluate the risks of infection deriving from treatment with BD and JAKi.

Proteome-wide Mendelian randomization identifies therapeutic targets for ankylosing spondylitis

Background

Ankylosing Spondylitis (AS) is a chronic inflammatory disorder which can lead to considerable pain and disability. Mendelian randomization (MR) has been extensively applied for repurposing licensed drugs and uncovering new therapeutic targets. Our objective is to pinpoint innovative therapeutic protein targets for AS and assess the potential adverse effects of druggable proteins.

Methods

We conducted a comprehensive proteome-wide MR study to assess the causal relationships between plasma proteins and the risk of AS. The plasma proteins were sourced from the UK Biobank Pharma Proteomics Project (UKB-PPP) database, encompassing GWAS data for 2,940 plasma proteins. Additionally, GWAS data for AS were extracted from the R9 version of the Finnish database, including 2,860 patients and 270,964 controls. The colocalization analysis was executed to identify shared causal variants between plasma proteins and AS. Finally, we examined the potential adverse effects of druggable proteins for AS therapy by conducting a phenome-wide association study (PheWAS) utilizing the extensive Finnish database in version R9, encompassing 2,272 phenotypes categorized into 46 groups.

Results

The findings revealed a positive genetic association between the predicted plasma levels of six proteins and an elevated risk of AS, while two proteins exhibited an inverse association with AS risk (P fdr < 0.05). Among these eight plasma proteins, colocalization analysis identified AIF1, TNF, FKBPL, AGER, ALDH5A1, and ACOT13 as shared variation with AS(PPH3+PPH4>0.8), suggesting that they represent potential direct targets for AS intervention. Further phenotype-wide association studies have shown some potential side effects of these six targets (P fdr < 0.05).

Conclusion

Our investigation examined the causal connections between six plasma proteins and AS, providing a comprehensive understanding of potential therapeutic targets.