No need to avoid TNF inhibitors in RA-ILD?

A real-world study with an active comparator found no significant differences in the risk of respiratory hospitalisation or death between patients with rheumatoid arthritis-interstitial lung disease (RA-ILD) who start non-TNF inhibitor/JAK inhibitor (non-TNFi/JAKi) versus TNF inhibitor (TNFi). These findings do not suggest TNFi should be avoided in RA-ILD.

Insufficient data exists to guide the selection of therapy in the context of RA-ILD. As such, a study designed by Dr Bryant England (University of Nebraska Medical Center, NE, USA) and his colleagues aimed to compare survival and respiratory-related outcomes in patients with RA-ILD who initiate treatment with TNFi or non-TNFi biologic/JAKi. This American group set up an active-comparator, new-user study of patients in the Veterans Health Administration (VA) between 2006 and 2018. The primary outcome was a composite of time to respiratory-related hospitalisation or death after 3 years. Secondary outcomes included respiratory hospitalisation and death after 1 year, because by that time, many patients were expected to have already made treatment adjustments.

Of 1,046 eligible RA-ILD patients, 237 TNFi initiators were matched to 237 non-TNFi/JAKi initiators in the primary analyses. The mean age was 68 years, and 92% were male. The most frequently used TNFi were adalimumab (51%) and etanercept (37%), while rituximab (53%) and abatacept (28%) were the most frequent non-TNFi/JAKi.

An increased risk of death or respiratory hospitalisation among RA-ILD patients who initiate a TNFi was not observed. The number of events was 108 in the non-TNFi/JAKi group versus 98 in the TNFi group (HR 1.21; 95% CI 0.92–1.59). No significant differences in the secondary outcomes were observed between both groups concerning mortality at year 3 (HR 1.11; 95% CI 0.78–1.58), respiratory hospitalisation at year 3 (HR 1.27; 95% CI 0.92–1.76), composite of death or respiratory hospitalisation at year 1 (HR 1.41; 95% CI 0.93–2.13), mortality at year 1 (HR 1.25; 95% CI 0.68–2.32), and respiratory hospitalisation at year 1 (HR 1.53; 95% CI 0.95–2.48).

The authors concluded that their findings do not support the need to systematically avoid TNFi to treat RA-ILD. However, various issues require clarification to make a well-informed choice between TNFi and non-TNFi/JAKi for these patients. It is still unknown if TNFi are safe in specific types of RA-ILD or specific subpopulations. Importantly, the above findings do not clarify whether TNFi are efficacious in RA-ILD. Data comparing the safety and efficacy of different DMARDs are needed to guide treatment decisions further.

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   1. England B, et al. Non-TNFi b/tsDMARDs vs. TNFi in rheumatoid arthritis-interstitial lung disease: An active-comparator, new-user, propensity score matched study using national veterans affairs data. 1582, ACR Convergence 2023, 10–15 November, San Diego, USA.

 

Medical writing support was provided by Michiel Tent.
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Posted on 1 December 20231 December 2023