January 26, 2021
What are the features and risk factors for anti-TNF-related demyelination?
Demyelination events are rare on anti-TNF therapy, but females and patients not given a concomitant immunomodulator may be at increased risk.
Lin S, Green HD, Hendy P, et al. Clinical Features and Genetic Risk of Demyelination Following Anti-TNF Treatment. J Crohn’s Colit. 2020;14(12):1653–61; https://doi.org/10.1093/ecco-jcc/jjaa104
Prior research has documented a two-fold increased risk of central demyelinating disease among IBD patients receiving anti-tumor necrosis factor (TNF) agents. (JAMA Intern Med. 2015;175(12):1990–92). To further understand this association, researchers performed a case-control study of 48 patients from 47 sites who received anti-TNF treatments and experienced demyelination. Each case was matched to five controls drawn from anti-TNF recipients recruited to the Personalising Anti-TNF Therapy in Crohn’s disease (PANTS) study who did not develop demyelination or any other neurological complication.
Indications for anti-TNF use included IBD in 60% of those with demyelination, rheumatoid arthritis in 23%, psoriasis in 13% and ankylosing spondylitis in 9%. Infliximab was used in 47% of patients with demyelination, while adalimumab was used in 36%, etanercept in 13%, certolizumab in 2% and golimumab in 2%.
In a propensity-matched comparison to controls, cases were more likely to be female (84% vs. 58%, p=0.008) and less likely to have received a concomitant immunomodulator (31% vs. 56%, p=0.02).
The median duration of anti-TNF treatment prior to demyelination was 9.9 months (Range: 5.1 to 31.9 months). Most cases of demyelination affected the brain, spinal cord, or both. Roughly one quarter of patients experienced complete recovery after a median time of 6.8 months [Range: 0.1–28.7]. Another 55% experienced partial recovery within 33 months of follow-up, while 17% had relapsing and remitting episodes, 6% had progressive symptoms and 4% were diagnosed with multiple sclerosis (MS). A genetic predisposition to MS was not associated with a greater likelihood of anti-TNF related demyelination.
Study Design: Retrospective case-control
Funding: Guts UK and the international Serious Adverse Events Consortium.
Allocation: Not applicable
Level of Evidence: 3b