Benefits of tumor necrosis factor inhibitors for cardiovascular disease in ankylosing spondylitis
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Published on: October 27, 2023
Jin-Xian Huang1, Yung-Heng Lee2, James Cheng-Chung Wei3
1Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
Insights
Ankylosing spondylitis patients face higher cardiovascular disease (CVD) risk. Tumor necrosis factor inhibitors (TNFi) may benefit CVD-vulnerable patients by controlling inflammation, but results on lipids and atherosclerosis are mixed.
Area of Science:
- Rheumatology
- Cardiology
- Immunology
Background:
- Ankylosing spondylitis (AS) is linked to increased cardiovascular disease (CVD) risk.
- Current guidelines recommend multiple CVD risk assessment strategies for AS patients.
- Subclinical atherosclerosis screening and surrogate markers are potential CVD risk predictors.
Purpose of the Study:
- To review the evidence on the effects of tumor necrosis factor inhibitors (TNFi) on CVD in AS patients.
- To explore the potential of TNFi in preventing microvascular events by inhibiting inflammation.
- To discuss the controversial findings regarding TNFi's impact on lipids and atherosclerosis.
Main Methods:
- Narrative review of existing literature.
- Summarization of studies investigating TNFi effects on CVD markers in AS.
- Analysis of factors contributing to controversial results in TNFi studies.
Main Results:
- While early reports noted CVD during TNFi treatment, recent evidence suggests successful management.
- Studies on TNFi's effects on lipid profiles and subclinical atherosclerosis in AS yield conflicting results.
- Potential reasons for conflicting results include genetic factors, varying TNFi efficacy, and insufficient follow-up duration.
Conclusions:
- Long-term TNFi administration can benefit AS patients vulnerable to CVD, provided inflammation is controlled.
- Managing traditional CVD risk factors and metabolic syndrome is crucial alongside lifestyle modifications.
- Further assessment and treatment of metabolic syndrome-related diseases are recommended for AS patients.
Abstract:
Ankylosing spondylitis (AS) has been associated with an increased cardiovascular disease (CVD) risk, with current guidelines recommending multiple CVD-related risk assessment strategies. CVD risk prediction using a scoring model with lipids might be another promising alternative, for which ultrasound screening for subclinical atherosclerosis may be considered together with surrogate markers. Theoretically, tumor necrosis factor inhibitors (TNFi), which are known to inhibit endothelial activation and inflammation caused by the disease and underlying metabolic dysfunction, might prevent microvascular events. In this narrative review, we summarized the evidence of TNFi effects on CVD in AS. Although early case reports revealed that CVD occurred during TNFi treatment, more recent evidence shows that it could be successfully treated. Studies of TNFi on lipid changes and subclinical atherosclerosis have shown controversial results, possibly due to genetic predisposition, differences in affinity for membrane-bound TNF leading to insufficient inhibition of inflammation or primary failure response to TNFi, and not enough follow-up time to identify potential significance. Overall, patients vulnerable to CVD could benefit from long-term administration of TNFi when inflammation is under control. Besides healthy lifestyle modification, traditional CVD risk factors and metabolic syndrome-related diseases should be further assessed and treated if necessary.
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