Issue 02

Clinical Question

What are the features and risk factors for anti-TNF-related demyelination?

Editor’s Bottom Line

Demyelination events are rare on anti-TNF therapy, but females and patients not given a concomitant immunomodulator may be at increased risk.

Reference

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

Synopsis

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.

Details

Study Design: Retrospective case-control

Funding: Guts UK and the international Serious Adverse Events Consortium.

Allocation: Not applicable

Setting: Multicenter

Level of Evidence: 3b

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.