Lower venous thromboembolism risk with TNF inhibitors in rheumatoid arthritis

Treatment of rheumatoid arthritis patients with tumour necrosis factor (TNF) inhibitors shows a significantly lower risk of serious venous thromboembolism (VTE) events compared with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

Treatment of rheumatoid arthritis patients with tumour necrosis factor (TNF) inhibitors shows a significantly lower risk of serious venous thromboembolism (VTE) events compared with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). However, the risk of VTE increases in patients older than 65 years harbouring high C-reactive protein (CRP) levels [1].

In rheumatoid arthritis, the short-term use of biological (b)DMARDs (i.e. ≤180 days) has been associated with an increased risk of VTE, while the long-term use (i.e. >730 days) has been associated with a decreased risk of developing VTE [2]. Previous observational data from patients with inflammatory bowel disease (IBD) suggested that TNF inhibitors may have a protective effect regarding VTE risk [3].

Dr Anja Strangfeld (Deutsches Rheuma-Forschungszentrum, Germany) and colleagues aimed to assess the effects of TNF inhibitors and newer bDMARDs (including abatacept, rituximab, sarilumab, and tocilizumab) on VTE risk [1]. The study analysed data from the German register RABBIT, which is a prospective, longitudinally followed cohort of RA patients who started a DMARD after at least one csDMARD failure. The registry includes over 10,000 patients starting a bDMARD between January 2009 and April 2019 and who had at least one follow-up.

Results from the analysis by Dr Strangfeld et al. showed that RA patients on TNF inhibitors (n=5,060) or other bDMARDs (n=2,534) had higher CRP levels and a higher prevalence of cardiovascular diseases at baseline than patients who were treated with csDMARDs (n=3,500). These patients also received glucocorticoids more frequently. For patients using a TNF inhibitor versus those on csDMARDS, the hazard ratio (HR) was 0.53 for a serious VTE event. For patients receiving other bDMARDs, the HR for a serious VTE event was 0.66. Patients with a CRP level >5 mg/L had a HR of 2.09; being older than 65 years also increased the risk (HR 2.96), while better physical function was associated with a decreased risk for VTE.

Sources:
1. Schaefer M, et al. TNF inhibitors are associated with a reduced risk of venous thromboembolism compared to CsDMARDs in RA patients. Abstract OP0012. EULAR E-Congress, 3-6 June 2020.
2. Kim SC, et al. Risk of Venous Thromboembolism in Patients With Rheumatoid Arthritis: Initiating Disease-Modifying Antirheumatic Drugs. Am J Med. 2015;128(5):539.e7–539.e17.
3. Desaj RJ, et al. Comparative risk of incident venous thromboembolism in patients with inflammatory bowel disease initiating tumour necrosis factor-α inhibitors or nonbiologic agents: a cohort study. CMAJ. 2017;189:E1438-47.

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