SAN FRANCISCO – Adalimumab was the clear winner over infliximab and etanercept for anterior uveitis in a Scandinavian database study of 1,365 patients with ankylosing spondylitis.
Office visits for uveitis dropped from 42.6 to 13.4 per 100 patient-years for the 406 patients who started on adalimumab (Humira). Flares per 100 patient-years dropped by almost 70%.
There was less improvement with infliximab (Remicade), which tended to be used in low doses in the study, less than 5 mg/kg. Office visits dropped from 50.4 to 27.3 per 100 patient-years for the 605 patients who started on it. Flares decreased by about 40%.
Etanercept (Enbrel), meanwhile, seemed to make uveitis worse, a concern that’s been raised previously. Office visits for uveitis increased from 38.1 to 56.5 per 100 patient-years for the 354 patients started on etanercept. Flares increased by about 20%.
Dr. Elisabeth Lie
The results were presented at the annual meeting of the American College of Rheumatology.
Among patients who were uveitis free in the 2 years prior to starting a tumor necrosis factor inhibitor (TNFi), the risk of flare was far greater with etanercept than with adalimumab (adjusted hazard ratio, 3.69; 95% confidence interval, 1.61-8.46). The risk also was higher for infliximab, though not significantly so (adjusted HR, 1.67; 95% CI, 0.69-4.04).
About 2% of adalimumab patients had their first bout of uveitis after starting it, versus 5.3% of infliximab and 13.7% of etanercept patients.
“A clear reduction in uveitis rates was observed for adalimumab, a slight reduction for infliximab, and a marked increase for etanercept, irrespective of the method for counting flares,” reported Dr. Elisabeth Lie, a rheumatology fellow at Gothenburg (Sweden) University.
In the adjusted analysis, “adalimumab and infliximab were associated with significantly lower hazard for first uveitis flare than etanercept,” noted Dr. Lie.
“Right now, we are still favoring infliximab because it comes as a biosimilar, so it’s inexpensive; I think we are giving it the benefit of the doubt. Still, these results are so favorable for adalimumab” that they make “a strong case to at least have a lower threshold to switch to it if you are not successful with your first choice,” Dr. Lie said in an interview.
The etanercept findings are “at least a reminder that if you have a patient with any history of uveitis, choose another option. I’ve seen a few” cases apparently triggered by etanercept. When that happens, “switch to something else,” she said.
The problem with etanercept may be related to its structure or immunologic effects, but no one really knows for sure, she added.
The study linked the first-time use of a TNFi by ankylosing spondylitis patients in the Swedish Biologics Register to their office visits for anterior uveitis as captured in the country’s National Patient Register. Dr. Lie and her coinvestigators analyzed the 2 years before and after the start of a TNFi. Adalimumab was more frequently used toward the end of the study period, which ran from 2003 through 2010.
Patients were in their early 40s, on average, and almost three-quarters were men. Infliximab patients most often used concomitant disease-modifying antirheumatic drugs and had the highest rate of comorbid inflammatory bowel disease, at 10.4%. Adalimumab patients had the lowest median baseline C-reactive protein at 10 mg/L, but highest pretreatment rate of uveitis, at 28%.
Dr. Lie is a speaker and consultant for AbbVie, the maker of adalimumab, and Pfizer, the maker of etanercept.