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Charles-Schoeman C, Fleischmann R, Mysler E, Greenwald M, Ytterberg SR, Koch GG, Bhatt DL, Wang C, Mikuls TR, Chen AS, Connell CA, Woolcott JC, Menon S, Chen Y, Lee K, Szekanecz Z. Risk of Venous Thromboembolism With Tofacitinib Versus Tumor Necrosis Factor Inhibitors in Cardiovascular Risk-Enriched Rheumatoid Arthritis Patients. Arthritis Rheumatol 2024; 76:1218-1229. [PMID: 38481002 DOI: 10.1002/art.42846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/19/2024] [Accepted: 03/12/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The ORAL Surveillance trial found a dose-dependent increase in venous thromboembolism (VTE) and pulmonary embolism (PE) events with tofacitinib versus tumor necrosis factor inhibitors (TNFi). We aimed to assess VTE incidence over time and explore risk factors of VTE, including disease activity, in ORAL Surveillance. METHODS Patients with rheumatoid arthritis (RA) aged 50 years or older with at least one additional cardiovascular risk factor received tofacitinib 5 or 10 mg twice daily (BID) or TNFi. Post hoc, cumulative probabilities and incidence rates (patients with first events/100 patient-years) by 6-month intervals were estimated for adjudicated VTE, deep vein thrombosis, and PE. Cox regression models identified risk factors. Clinical Disease Activity Index leading up to the event was explored in patients with VTE. RESULTS Cumulative probabilities for VTE and PE were higher with tofacitinib 10 mg BID, but not 5 mg BID, versus TNFi. Incidence rates were consistent across 6-month intervals within treatments. Across treatments, risk factors for VTE included prior VTE, body mass index greater than or equal to 35 kg/m2, older age, and history of chronic lung disease. At the time of the event, most patients with VTE had active disease as defined by Clinical Disease Activity Index. CONCLUSION Incidences of VTE and PE were higher with tofacitinib (10 > 5 mg BID) versus TNFi and were generally consistent over time. Across treatments, VTE risk factors were aligned with previous studies in the general RA population. These data highlight the importance of assessing VTE risk factors, including age, body mass index, and VTE history, when considering initiation of tofacitinib or TNFi in patients with active RA.
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Affiliation(s)
| | - Roy Fleischmann
- Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | | | | | - Gary G Koch
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | - Ted R Mikuls
- University of Nebraska Medical Center and Veterans Affairs Nebraska Western Iowa Health Care System, Omaha, Nebraska
| | | | | | | | | | - Yan Chen
- Pfizer Inc, Collegeville, Pennsylvania
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Citera G, Mysler E, Kakehasi AM, Pascual-Ramos V, Masson W, Cadatal MJ, Rivas JL, Sheibanie F, Helling C, Ponce de Leon D. Cardiovascular Events, Malignancies, and Efficacy Outcomes in Latin American Patients With Rheumatoid Arthritis Receiving Tofacitinib or Tumor Necrosis Factor Inhibitors: A Post Hoc Analysis of the ORAL Surveillance Study. J Clin Rheumatol 2024; 30:208-216. [PMID: 38880956 DOI: 10.1097/rhu.0000000000002106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
BACKGROUND/OBJECTIVE To assess safety/efficacy of tofacitinib and tumor necrosis factor inhibitors (TNFi) in patients from Latin America (LATAM) in ORAL Surveillance. METHODS In ORAL Surveillance, 4362 patients with rheumatoid arthritis aged ≥50 years with ≥1 additional cardiovascular risk factor received tofacitinib 5 or 10 mg twice daily or TNFi. This post hoc analysis stratified patients by geographical location (LATAM, n = 1202; non-LATAM, n = 3160). Incidence rates (IRs; patients with first event/100 patient-years) and hazard ratios for adverse events of special interest were reported. Efficacy outcomes included Clinical Disease Activity Index and American College of Rheumatology 20/50/70 responses. RESULTS Risk factors associated with cardiovascular disease and malignancies were less prevalent in the LATAM cohort compared with the non-LATAM cohort. IRs for patients receiving tofacitinib (combined doses) versus TNFi were 0.54 versus 0.28 (LATAM) and 1.14 versus 0.92 (non-LATAM) for major adverse cardiovascular events; 0.58 versus 0.27 (LATAM) and 1.33 versus 0.95 (non-LATAM) for malignancies excluding nonmelanoma skin cancer; and 0.69 versus 0.35 (LATAM) and 0.63 versus 0.33 (non-LATAM) for all-cause death. IRs for nonmelanoma skin cancer and venous thromboembolism were also numerically higher with tofacitinib versus TNFi and in the non-LATAM cohort versus LATAM. Efficacy was similar across treatment groups within each cohort. CONCLUSIONS Adverse events of special interest were generally less frequent in LATAM versus non-LATAM patients, reflecting differences in baseline characteristics, and higher with tofacitinib versus TNFi in both cohorts, consistent with the overall findings of ORAL Surveillance. Our findings emphasize the importance of assessing individual risk factors to guide benefit/risk assessment and treatment decisions. CLINICAL TRIAL REGISTRATION NUMBER NCT02092467.
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Affiliation(s)
- Gustavo Citera
- From the Section of Rheumatology, Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | - Adriana Maria Kakehasi
- Serviço de Reumatologia do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Virginia Pascual-Ramos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, Mexico
| | - Walter Masson
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Karpouzas GA, Ormseth SR, van Riel PLCM, Gonzalez-Gay MA, Corrales A, Rantapää-Dahlqvist S, Sfikakis PP, Dessein P, Tsang L, Hitchon C, El-Gabalawy H, Pascual-Ramos V, Contreras-Yáñez I, Colunga-Pedraza IJ, Galarza-Delgado DA, Azpiri-Lopez JR, Semb AG, Misra DP, Hauge EM, Kitas G. Biological use influences the impact of inflammation on risk of major adverse cardiovascular events in rheumatoid arthritis. RMD Open 2024; 10:e004546. [PMID: 39043615 PMCID: PMC11268070 DOI: 10.1136/rmdopen-2024-004546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 07/05/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVES Chronic inflammation promotes cardiovascular risk in rheumatoid arthritis (RA). Biological disease-modifying antirheumatic drugs (bDMARDs) improve disease activity and cardiovascular disease outcomes. We explored whether bDMARDs influence the impact of disease activity and inflammatory markers on long-term cardiovascular risk in RA. METHODS We studied 4370 participants without cardiovascular disease in a 10-country observational cohort of patients with RA. Endpoints were (1) major adverse cardiovascular events (MACE) encompassing myocardial infarction, stroke and cardiovascular death; and (2) any ischaemic cardiovascular events (iCVE) including MACE plus revascularisation, angina, transient ischaemic attack and peripheral arterial disease. RESULTS Over 26 534 patient-years, 239 MACE and 362 iCVE occurred. The interaction between 28-joint Disease Activity Score with C-reactive protein (DAS28-CRP) and bDMARD use was significant for MACE (p=0.017), suggesting the effect of DAS28-CRP on MACE risk differed among bDMARD users (n=515) and non-users (n=3855). DAS28-CRP (per unit increase) is associated with MACE risk in bDMARD non-users (HR 1.21 (95% CI 1.07 to 1.37)) but not users (HR 0.69 (95% CI 0.40 to 1.20)). The interaction between CRP (per log unit increase) and bDMARD use was also significant for MACE (p=0.011). CRP associated with MACE risk in bDMARD non-users (HR 1.16 (95% CI 1.04 to 1.30)), but not users (HR 0.65 (95% CI 0.36 to 1.17)). No interaction was observed between bDMARD use and DAS28-CRP (p=0.167) or CRP (p=0.237) for iCVE risk. CONCLUSIONS RA activity and inflammatory markers associated with risk of MACE in bDMARD non-users but not users suggesting the possibility of biological-specific benefits locally on arterial wall independently of effects on systemic inflammation.
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Affiliation(s)
- George Athanasios Karpouzas
- Internal Medicine - Rheumatology, The Lundquist Institute, Torrance, California, USA
- Rheumatology, Harbor-UCLA Medical Center, Torrance, California, USA
| | | | | | - Miguel A Gonzalez-Gay
- Rheumatology, Hospital Universitario Marques de Valdecilla, Santander, Cantabria, Spain
- IIS-Fundacion Jimenez Diaz, Madrid, Spain
| | - Alfonso Corrales
- Hospital Universitario Marques de Valdecilla, Santander, Cantabria, Spain
| | | | - Petros P Sfikakis
- First Dept. of Propedeutic Medicine, University of Athens, Athens, Attica, Greece
| | - Patrick Dessein
- School of Physiology, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | - Linda Tsang
- Vrije Universiteit Brussel, Brussel, Belgium
| | - Carol Hitchon
- Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hani El-Gabalawy
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Virginia Pascual-Ramos
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico City, Mexico
| | - Irazú Contreras-Yáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | - Iris J Colunga-Pedraza
- Rheumatology, Hospital Universitario Dr José Eleuterio González, Monterrey, Nuevo León, Mexico
| | | | | | - Anne Grete Semb
- Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Durga Prasanna Misra
- Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ellen-Margrethe Hauge
- Department of Joint and Connective Tissue Diseases, Aarhus Universitetshospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Midtjylland, Denmark
| | - George Kitas
- Department of Rheumatology, The Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
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Saito K, Yoshida S, Ebina H, Miyata M, Suzuki E, Kanno T, Sumichika Y, Matsumoto H, Temmoku J, Fujita Y, Matsuoka N, Asano T, Sato S, Migita K. Real-world comparative study of drug retention of Janus kinase inhibitors in patients with rheumatoid arthritis. PLoS One 2024; 19:e0306714. [PMID: 38990897 PMCID: PMC11239012 DOI: 10.1371/journal.pone.0306714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/22/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Janus kinase (JAK) inhibitors (JAKis) are effective therapeutic agents against rheumatoid arthritis (RA). However, patients having RA with particular risk factors may have a higher incidence of adverse effects (AEs), including major cardiovascular events (MACE) and infections. In this multicenter cohort study, we aimed to clarify the risk factors affecting the drug retention of JAKis in patients with RA. METHODS We retrospectively evaluated patients with RA who received their first JAKi (tofacitinib, baricitinib, upadacitinib, or filgotinib) at our institute. The clinical outcomes, including AEs, were recorded, particularly MACE and serious infections. The drug retention rates were analyzed using the Kaplan-Meier method, and risk factors affecting drug retention rates were determined using a multivariable Cox regression hazards model. RESULTS Overall 184 patients with RA receiving their first use of baricitinib (57.6%), tofacitinib (23.9%), upadacitinib (12.0%), or filgotinib (6.5%) were included in this study. Fifty-six (30.4%) patients discontinued JAKi treatment owing to ineffectiveness (9.2%) or AEs, including infections (21.2%). The overall drug retention rates were significantly lower in patients treated with pan-JAKi than in those treated with JAK1 inhibitors (p = 0.03). In the Cox regression model, the presence of baseline high RA disease activity, use of glucocorticoid and treatments with pan-JAKis were associated with reduced drug retention rates of JAKis (p < 0.001, p = 0.01 and 0.04, respectively). Pan-JAKi treated patients with high disease activity had significantly lower drug retention rates (p < 0.001). CONCLUSIONS In a real-world setting, the drug retention rates of JAKis were reduced mainly by treatment discontinuation owing to AEs. Treatment with pan-JAKis and high baseline RA disease activity were identified as predictive factors for the discontinuation of JAKis. Lower drug retention rates were found in patients receiving pan-JAKis with high disease activity than in those without high disease activity.
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Affiliation(s)
- Kenji Saito
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shuhei Yoshida
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Honoka Ebina
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masayuki Miyata
- Department of Rheumatology, Japanese Red Cross Fukushima Hospital, Fukushima, Japan
| | - Eiji Suzuki
- Department of Rheumatology, Ohta Nishinouchi General Hospital Foundation, Koriyama, Fukushima, Japan
| | - Takashi Kanno
- Department of Rheumatology, Ohta Nishinouchi General Hospital Foundation, Koriyama, Fukushima, Japan
| | - Yuya Sumichika
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Haruki Matsumoto
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Rheumatology, St. Francis Hospital, Nagasaki, Japan
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Kristensen LE, Deodhar A, Leung YY, Vranic I, Mortezavi M, Fallon L, Yndestad A, Kinch CD, Gladman DD. Risk Stratification of Patients with Psoriatic Arthritis and Ankylosing Spondylitis for Treatment with Tofacitinib: A Review of Current Clinical Data. Rheumatol Ther 2024; 11:487-499. [PMID: 38696034 PMCID: PMC11111604 DOI: 10.1007/s40744-024-00662-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/08/2024] [Indexed: 05/23/2024] Open
Abstract
In this commentary, we review clinical data which helps inform individualized benefit-risk assessment for tofacitinib in patients with psoriatic arthritis (PsA) and ankylosing spondylitis (AS). ORAL Surveillance, a safety trial of patients ≥ 50 years of age with rheumatoid arthritis (RA) and cardiovascular risk factors, found increased rates of safety outcomes (including major adverse cardiovascular events [MACE], malignancies excluding non-melanoma skin cancer, and venous thromboembolism) with tofacitinib versus tumor necrosis factor inhibitors (TNFi). Post hoc analyses of ORAL Surveillance have identified subpopulations with different relative risk versus TNFi; higher risk with tofacitinib was confined to patients ≥ 65 years of age and/or long-time current/past smokers, and specifically for MACE, patients with a history of atherosclerotic cardiovascular disease (ASCVD). In patients without these risk factors, risk differences between tofacitinib and TNFi could not be detected. Given differences in demographics, pathophysiology, and comorbidities, we sought to examine whether the risk stratification observed in RA is also appropriate for PsA and AS. Data from the PsA tofacitinib development program show low absolute risk of safety outcomes in patients < 65 years of age and never smokers, and low MACE risk in patients with no history of ASCVD, consistent with results from ORAL Surveillance. No MACE, malignancies, or venous thromboembolism were reported in the tofacitinib AS development program. The mechanism of the ORAL Surveillance safety findings is unknown, and there are no similar prospective studies of sufficient size and duration. Accordingly, it is appropriate to use a precautionary approach and extrapolate differentiating risk factors identified from ORAL Surveillance (age ≥ 65 years, long-time current/past smoking, and history of ASCVD) to PsA and AS. We recommend an individualized approach to treatment decisions based on these readily identifiable risk factors, in line with updated labeling for Janus kinase inhibitors and international guidelines for the treatment of PsA and AS.Trial Registration: NCT02092467, NCT01262118, NCT01484561, NCT00147498, NCT00413660, NCT00550446, NCT00603512, NCT00687193, NCT01164579, NCT00976599, NCT01059864, NCT01359150, NCT02147587, NCT00960440, NCT00847613, NCT00814307, NCT00856544, NCT00853385, NCT01039688, NCT02281552, NCT02187055, NCT02831855, NCT00413699, NCT00661661, NCT01877668, NCT01882439, NCT01976364, NCT00678210, NCT01710046, NCT01241591, NCT01186744, NCT01276639, NCT01309737, NCT01163253, NCT01786668, NCT03502616.
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Affiliation(s)
- Lars Erik Kristensen
- The Parker Institute, Bispebjerg and Frederiksberg, Copenhagen, Denmark.
- Copenhagen University, Copenhagen, Denmark.
| | - Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Ying-Ying Leung
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | | | | | | | | | | | - Dafna D Gladman
- Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
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Szekanecz Z, Buch MH, Charles-Schoeman C, Galloway J, Karpouzas GA, Kristensen LE, Ytterberg SR, Hamar A, Fleischmann R. Efficacy and safety of JAK inhibitors in rheumatoid arthritis: update for the practising clinician. Nat Rev Rheumatol 2024; 20:101-115. [PMID: 38216757 DOI: 10.1038/s41584-023-01062-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/14/2024]
Abstract
Janus kinase (JAK) inhibitors, including tofacitinib, baricitinib, upadacitinib and filgotinib, are increasingly used in the treatment of rheumatoid arthritis (RA). There has been debate about their safety, particularly following the issuance of guidance by regulatory agencies advising caution in their use in certain patients. The registrational clinical trials and registry data of JAK inhibitors did not identify a difference in the risk of major adverse cardiovascular events (MACEs), venous thromboembolism, malignancies or infections (other than herpes zoster) with a JAK inhibitor versus a biologic DMARD. In the ORAL Surveillance trial, which enrolled patients >50 years of age with ≥1 cardiovascular risk factor, tofacitinib was statistically inferior to TNF inhibitors for the occurrence of MACEs and malignancy. Further post hoc analysis of the data revealed that an age of ≥65 years, a high baseline cardiovascular risk, a history of smoking, sustained inflammation, disease activity and suboptimal treatment of cardiovascular comorbidities all increase the risk of these outcomes. The guidance issued by regulatory agencies should be carefully considered to ensure appropriate and safe treatment of patients with RA without undertreatment of patients who might benefit from JAK inhibitor, as well as biologic, treatment. As always, the risks associated with the use of these agents, treatment goals, costs and patient preferences should be discussed with the patient.
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Affiliation(s)
- Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Maya H Buch
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Christina Charles-Schoeman
- Division of Rheumatology, Department of Medicine, Harbour-University of California Los Angeles Medical Centre, Los Angeles, CA, USA
| | - James Galloway
- Department of Inflammation Biology and Centre for Rheumatic Diseases, King's College London, London, UK
| | - George A Karpouzas
- Division of Rheumatology, Department of Medicine, Harbour-University of California Los Angeles Medical Centre, Los Angeles, CA, USA
| | - Lars Erik Kristensen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Attila Hamar
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roy Fleischmann
- Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas, TX, USA
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