What are the risks and benefits of TNF-α inhibitors for the treatment of ankylosing spondylitis (AS) and undifferentiated spondyloarthropathy (USpA)?

Updated: Feb 02, 2021
  • Author: Lawrence H Brent, MD; Chief Editor: Herbert S Diamond, MD  more...
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There is some concern regarding an increased risk of malignancy in patients receiving TNFi. The most attention has been focused on lymphoma and non-melanotic skin cancers in patients with rheumatoid arthritis, although this has been difficult to document in such patients and has not been described in patients with AS. In rare cases, cytopenias have been associated with TNFi use.

Patients with rheumatoid arthritis who have recently started TNFi may be at increased risk for new-onset congestive heart failure even in the absence of any obvious risk factors for the disease. These agents should not be initiated in patients with uncompensated congestive heart failure.

Patients should be screened for latent tuberculosis, hepatitis B, and HIV infection before beginning TNFi therapy. [126] Although these agents should not be used in patients with active hepatitis B infection, they appear to be safe in patients with chronic hepatitis C infections. Rarely, autoimmune syndromes (eg, a lupus-like illness) have been noted in patients receiving TNFi. More commonly, a positive antinuclear antibody (ANA) test result, in the absence of clinical disease, may occur during treatment.

Demyelinating syndromes have rarely been documented in patients receiving TNFi, though no direct link has been proved. These agents should not be used in patients with multiple sclerosis or other demyelinating diseases. New-onset psoriatic skin lesions have been documented after the initiation of TNFi.

In a prospective study of 334 patients with AS, response to treatment with TNFi was associated with a 50% reduction in the risk of radiographic progression of AS. However, nearly 4 years of treatment were necessary for the benefit to become apparent. Moreover, in patients who first began TNFi treatment 10 or more years after disease onset, AS progression was twice as likely as it was in patients who started treatment earlier. [127, 128]

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