Safety of Resuming Tumor Necrosis Factor Inhibitors in Ankylosing Spondylitis Patients Concomitant with the Treatment of Active Tuberculosis: A Retrospective Nationwide Registry of the Korean Society of Spondyloarthritis Research

Abstract

BackgroundsPatients who develop an active tuberculosis infection during tumor necrosis factor (TNF) inhibitor treatment typically discontinue TNF inhibitor and receive standard anti-tuberculosis treatment. However, there is currently insufficient information on patient outcomes following resumption of TNF inhibitor treatment during ongoing anti- tuberculosis treatment. Our study was designed to investigate the safety of resuming TNF inhibitors in ankylosing spondylitis (AS) patients who developed tuberculosis as a complication of the use of TNF inhibitors.MethodsThrough the nationwide registry of the Korean Society of Spondyloarthritis Research, 3929 AS patients who were prescribed TNF inhibitors were recruited between June 2003 and June 2014 at fourteen referral hospitals. Clinical information was analyzed about the patients who experienced tuberculosis after exposure to TNF inhibitors. The clinical features of resumers and non-resumers of TNF inhibitors were compared and the outcomes of tuberculosis were surveyed individually.FindingsFifty-six AS patients were treated for tuberculosis associated with TNF inhibitors. Among them, 23 patients resumed TNF inhibitors, and these patients were found to be exposed to TNF inhibitors for a longer period of time and experienced more frequent disease flare-up after discontinuation of TNF inhibitors compared with those who did not resume. Fifteen patients resumed TNF inhibitors during anti-tuberculosis treatment (early resumers) and 8 after completion of anti-tuberculosis treatment (late resumers). Median time to resuming TNF inhibitor from tuberculosis was 3.3 and 9.0 months in the early and late resumers, respectively. Tuberculosis was treated successfully in all resumers and did not relapse in any of them during follow-up (median 33.8 [IQR; 20.8–66.7] months).ConclusionsInstances of tuberculosis were treated successfully in our AS patients, even when given concomitantly with TNF inhibitors. We suggest that early resumption of TNF inhibitors in AS patients could be safe under effective coverage of tuberculosis.

The role of ixekizumab in non-radiographic axial spondyloarthritis

“… 69 – 72 In addition, it is necessary to study further whether an IL-17 inhibitor may be an alternative treatment for patients who presented with tuberculosis reactivation during TNFi therapy. 73 , 74 …”

Advances in whole body MRI for musculoskeletal imaging: Diffusion-weighted imaging

“…Ankylosing spondylitis is a seronegative spondyloarthropathy that mainly involves the axial joints, including the sacroiliac joints and spine, and less frequently involves peripheral joints such as hips, knees, hands, or the thoracic wall. 38 In ankylosing spondylitis, long term inflammation of the bone and soft tissue in the spine and joints results in erosion, new bone formation, and eventually fusion (ankylosis). WB-MRI can evaluate and quantify synovitis, enthesitis, and juxtaarticular bone destruction (Fig.…”

The Safety Profile of Tumor Necrosis Factor Inhibitors in Ankylosing Spondylitis: Are TNF Inhibitors Safer Than We Thought?

“…ETN binds to membrane TNF on activated T cells more weakly than monoclonal antibodies, and thus to a lesser extent inhibit the activation of T cells and suppress the release of IFN‐γ, essential in host defense against TB . Interestingly, the reintroduction of TNF inhibitors in patients with ankylosing spondylitis with a history of TB after TNF inhibitors seems to be a safe option …”

“…40,41 Interestingly, the reintroduction of TNF inhibitors in patients with ankylosing spondylitis with a history of TB after TNF inhibitors seems to be a safe option. 42,43 Opportunistic Infections From 71 randomized controlled trials conducted through May 2014 in patients with RA, ankylosing spondylitis, and psoriatic arthritis treated with TNF inhibitors, only 6 randomized controlled trials (3886 participants, all with RA) have reported the occurrence of opportunistic infections (OIs) (0.3% in treatment groups; 0.3% in control groups). Meta-analysis of these studies found no evidence of increased odds of OI in the TNF inhibitor group (fixed-effects model: OR, 0.94; 95%CI, 0.33-2.64; random-effects model, OR, 0.81; 95%CI, 0.23-2.87).…”