Risk of Multiple Sclerosis Among Users of Antitumor Necrosis Factor α in 4 Canadian Provinces

Abstract

Background and Objectives:Anti-tumor necrosis factor alpha (TNFα) agents are a class of biologic drugs used for the treatment of several immune-mediated conditions. An increased risk of multiple sclerosis (MS) with their use has been suggested, but studies have been limited. Relevant population-based epidemiologic data linking anti-TNFα to MS are scarce. To compare the risk of MS in anti-TNFα users with non-users among rheumatic disease (RD) or inflammatory bowel disease (IBD) patients.Methods:A nested case-control study was conducted. Population-based healthcare linked databases from four Canadian provinces were used. All patients with RD or IBD residing within a participating province between January 2000 and March 2018 were identified by validated case definitions. Any anti-TNFα dispensation in the two years prior to the index date (MS onset) was identified. Incident-onset MS cases were ascertained using a validated algorithm. Up to five controls were matched to each MS case based on birth year ±3 years, disease duration, and health authority (based on region of residence). Conditional logistic regressions were used to calculate the incidence rate ratio (IRR) after adjusting for potential confounders. A meta-analysis was conducted to provide pooled estimates across provinces using random-effects models.Results:Among 296,918 RD patients, 462 MS cases (80.1% female, mean [SD] age, 47.4 [14.6] years) were matched with 2,296 controls (59.5% female, mean [SD] age, 47.4 [14.5] years). Exposure to anti-TNFα occurred in 18 MS cases and 42 controls. After adjusting for matching variables, sex, and the Charlson Comorbidity Index, the pooled IRR was 2.05 (95% CI, 1.13-3.72). Among 84,458 IBD patients, 190 MS cases (69.5% female, mean [SD] age, 44.3 [12.3] years) were matched with 943 controls (54.1% female, mean [SD] age, 44.2 [12.2]). Exposure to anti-TNFα occurred in 23 MS cases and 98 controls. The pooled adjusted IRR was 1.35 (95% CI, 0.70-2.59).Discussion:The use of anti-TNFα was associated with an increased risk of MS compared to non-users, especially among patients with RD. These findings could help clinicians and patients with RD to make more informed treatment decisions. Further studies are needed to validate these results for IBD patients.

The Genomic Architecture of Circulating Cytokine Levels Points to Drug Targets for Immune-Related Diseases

“…72,74 While TNF inhibition has demonstrated success in treating autoimmune diseases such as rheumatoid arthritis or psoriasis, patients undergoing anti-TNF therapy for these indications are at risk for developing demyelinating CNS lesions, indicating a disease-specific effect. 40,75 Supporting the clinical findings, GWAS studies in MS identified TNF lowering alleles for both cytokines TNF-a and TNF-b that were associated with higher risk for MS. 23,76 We provide additional genetic evidence in line with observational, clinical, and GWAS findings for a potentially protective role of TNF-b in MS.…”

Neuro-ophthalmic manifestations of autoimmune disorders: diagnostic pearls & pitfalls

“…Afferent and efferent visual manifestations of autoimmune diseases often share phenotypic features with common ischemic, infectious, and neoplastic neuro-ophthalmic syndromes. For this reason, carefully exploring the onset of the problem, clinical course, provoking or alleviating factors, comorbidities (particularly preestablished autoimmune diseases or cancers), associated symptoms, family history, and medication exposures may help identify an underlying autoimmune process (Table 1) [6][7][8][9][10][11][12][13][14]. Once the clinical localization and differential diagnosis are determined by history, suspected autoimmune mechanisms of a neuroophthalmic syndrome may be identified with a thorough examination.…”

Inflammatory Bowel Disease and Neurodegenerative Diseases

“… 2 Furthermore, patients with IBD or rheumatologic diseases have higher incidence of multiple sclerosis (MS) and vice versa. 3 - 5 While epidemiologic and clinical evidence are robust, pathophysiology remains uncertain.…”