Treatment-related heart failure risk for rheumatoid arthritis patients revealed

Rheumatoid arthritis (RA) patients have no greater risk for heart failure (HF) with tumor necrosis factor (TNF)-alpha therapy than with nonbiologic disease-modifying antirheumatic drugs (nbDMARDs), research suggests.

Analysis of data for 8656 new users of a nbDMARD gave a hazard ratio (HR) for HF of 0.85 compared with 11,587 new users of a TNF-alpha inhibitor, a nonsignificant difference between the groups after adjustment for oral glucocorticoid dosage, history of HF hospitalization, and use of loop diuretics.

For patients with a history of HF, there was no overall increase in the risk for HF when using TNF-alpha inhibitors, the researchers add.

Further analysis showed that there was a glucocorticoid dose-related gradient of HF risk, with a HR of 1.30 for a dose of 1 to <5 mg, and 1.54 for a dose of 5 mg or higher compared with no glucocorticoid treatment.

However, use of glucocorticoids did not alter the risk for HF associated with TNF-alpha inhibitor use.

"Whenever possible, the use of oral glucocorticoids should be limited; our data suggests that small reductions in dosage may ameliorate the risk of HF," write Daniel Solomon (Brigham and Women's Hospital, Boston, Massachusetts, USA) and co-authors.

They add: "Our findings regarding oral glucocorticoids suggest that studies of HF in RA, including clinical trials, need to carefully control for this important comedication."

The team comments: "Since the literature suggests that RA is associated with HF, presumably through the effects of inflammation on cardiac contractility, it is critical to better understand the effects of potent immunosuppressives on HF risk."

The study included patients from four US healthcare programs, and after trimming for propensity analysis, the 22,907 patients were mostly women (86%) and had an average age of 56 years. Patients in the nbDMARDs and TNF-alpha inhibitor groups had a similar history of stroke, myocardial infarction, and coronary revascularization, and a similar burden of cardiovascular risk factors such as hypertension and diabetes.

The incidence of HF in the nbDMARDs and TNF-alpha inhibitor groups were 3.15 and 2.49 cases per 100 person-years and comparable due to wide confidence intervals, the researchers report. Patients with a known history of HF were 10-15 times more likely to have HF than those without at a rate of 26.7-32.2 and 1.65-1.95 per 100 person-years, respectively.

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