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TNF Inhibitors Linked to Increased Multiple Sclerosis Risk

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Anti-tumor necrosis factor alpha (TNF-alpha) inhibitors are associated with an increased risk for multiple sclerosis (MS), especially among patients with rheumatic disease (RD), new research shows.

When investigators combed medical databases in four Canadian provinces for information on patients with RD and irritable bowel disease (IBD) taking anti-TNF-alpha agents alongside matched controls in a prospective cohort study, they found an increased risk for MS in the RD patients.



Dr Antonio Aviña-Zubieta

Physicians shouldn’t hesitate to prescribe anti-TNF-alpha therapy for patients if they believe their patients can benefit from it, study investigator Antonio Aviña-Zubieta, MD, PhD, senior scientist at Arthritis Research Canada in Vancouver, British Columbia, told Medscape Medical News.

“To better provide a context of the magnitude of the risk, we would need to treat 2268 individuals with anti-TNF-alpha therapy in order to get one additional case of MS. This is considered a rare side effect [of anti-TNF therapy],” he said, adding that MS still occurred even in people who did not receive anti-TNF therapy.

“Nevertheless, we do not recommend anti-TNF in patients with MS or those with a family history of MS. The decision to take anti-TNF is best taken together by patient and health care provider,” said Aviña-Zubieta.

The study was published online October 28 in the journal Neurology.

Potential MS Link Investigated

Anti-TNF-alpha agents are often prescribed to stop inflammation for chronic immune disorders such as rheumatoid arthritis, inflammatory bowel disease (IBD), psoriasis, and ankylosing spondylitis. Prior research has raised suspicions of an increased risk of MS with use of anti-TNF-alpha agents in small samples.

Investigators accessed population-linked databases in the Canadian provinces of British Columbia, Alberta, Saskatchewan, and Manitoba, which contain information about physician visits, hospitalizations, demographic data, and medication in those provinces.

They mined the databases for information about patients diagnosed with RD and IBD between January 2000 and March 2018 and then determined new incident cases of MS in the two disease cohorts with at least three outpatient records related to MS, hospitalizations, or prescription claims for MS. Investigators could only obtain information about RD from databases in BC and Manitoba.

The anti-TNF-alpha drugs were dispensed in the 2 years prior to MS onset, and included adalimumab, certolizumab, etanercept, infliximab, and golimumab.

Each case of MS was matched with up to five control subjects of similar ages who did not receive anti-TNF-alpha agents, had similar RD or IBD illness duration, and the same approximate place of residence.

Investigators identified nearly 300,000 patients with RD. During follow-up, 462 of them developed MS (80% female, mean age 47) and were matched with 2300 controls with RD (60% female, mean age 47). They found that 18 people with RD and MS took an anti-TNF-alpha, vs 42 of the 2296 patients who had RD but not MS.

After adjusting for variables that could influence the risk of developing MS, the investigators discovered that people with RD who took an anti-TNF-alpha agent had a 105% increased risk of developing MS compared to people with RD who didn’t take an anti-TNF-alpha agent.

Aviña-Zubieta said it would be ill-advised for people with RD who have a family history of MS to use the anti-TNF agents, as there are other medications that could also be helpful.

Investigators noted a smaller increased risk for MS in the group with IBD, but the findings did not reach statistical significance.

There are several theories about how anti-TNF therapy might risk MS in certain patients. Aviña-Zubieta speculated that the therapy may increase reactivity from immune cells to myelin leading to a loss and malfunction of the affected areas. Additionally, “TNF blockage by this therapy may affect myelin repair. The possibility of higher risk of infections that could be linked to MS is possible too, but not proven,” he noted.

Study limitations included smaller sample sizes from Saskatchewan and Manitoba. Investigators also noted that MS prodrome periods can occur as much as 5 years before onset, so patients exhibiting early MS symptoms or MS prodrome who have not yet been diagnosed might be misdiagnosed as controls.

Context Is Important

Commenting on the study for Medscape Medical News, Amy Kunchok, MD, a staff neurologist at the Cleveland Clinic’s Mellen Center for Multiple Sclerosis, Cleveland, Ohio said context is important when interpreting the findings.



Dr Amy Kunchok

“Anti-TNF therapies are highly effective for many autoimmune disorders, as evidenced by numerous randomized controlled trials in rheumatological disorders and IBD,” said Kunchok, who was not involved in the study.

“As with any therapeutic decision, the physician needs to consider the medical needs of the patient and the risk–benefit scenario. In a patient with a preexisting MS diagnosis, we would generally not recommend these therapies, but instead suggest the treating specialist consider alternatives.

“However, in patients without prior inflammatory neurological disorders, these therapies may be safe and efficacious. There is more work needed to risk- stratify patients in terms of these rare inflammatory CNS events,” she added.

Neurology. Published online October 28, 2022. Abstract

The study was funded by the Canadian Institutes of Health Research. Aviña-Zubieta and Kunchok report no relevant financial relationships.

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Some Ontario docs now offering RSV shot to infants with Quebec rollout set for Nov.

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Some Ontario doctors have started offering a free shot that can protect babies from respiratory syncytial virus while Quebec will begin its immunization program next month.

The new shot called Nirsevimab gives babies antibodies that provide passive immunity to RSV, a major cause of serious lower respiratory tract infections for infants and seniors, which can cause bronchiolitis or pneumonia.

Ontario’s ministry of health says the shot is already available at some doctor’s offices in Ontario with the province’s remaining supply set to arrive by the end of the month.

Quebec will begin administering the shots on Nov. 4 to babies born in hospitals and delivery centers.

Parents in Quebec with babies under six months or those who are older but more vulnerable to infection can also book immunization appointments online.

The injection will be available in Nunavut and Yukon this fall and winter, though administration start dates have not yet been announced.

This report by The Canadian Press was first published Oct. 21, 2024.

-With files from Nicole Ireland

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

The Canadian Press. All rights reserved.

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Polio is rising in Pakistan ahead of a new vaccination campaign

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ISLAMABAD (AP) — Polio cases are rising ahead of a new vaccination campaign in Pakistan, where violence targeting health workers and the police protecting them has hampered years of efforts toward making the country polio-free.

Since January, health officials have confirmed 39 new polio cases in Pakistan, compared to only six last year, said Anwarul Haq of the National Emergency Operation Center for Polio Eradication.

The new nationwide drive starts Oct. 28 with the aim to vaccinate at least 32 million children. “The whole purpose of these campaigns is to achieve the target of making Pakistan a polio-free state,” he said.

Pakistan regularly launches campaigns against polio despite attacks on the workers and police assigned to the inoculation drives. Militants falsely claim the vaccination campaigns are a Western conspiracy to sterilize children.

Most of the new polio cases were reported in the southwestern Balochistan and southern Sindh province, following by Khyber Pakhtunkhwa province and eastern Punjab province.

The locations are worrying authorities since previous cases were from the restive northwest bordering Afghanistan, where the Taliban government in September suddenly stopped a door-to-door vaccination campaign.

Afghanistan and Pakistan are the two countries in which the spread of the potentially fatal, paralyzing disease has never been stopped. Authorities in Pakistan have said that the Taliban’s decision will have major repercussions beyond the Afghan border, as people from both sides frequently travel to each other’s country.

The World Health Organization has confirmed 18 polio cases in Afghanistan this year, all but two in the south of the country. That’s up from six cases in 2023. Afghanistan used a house-to-house vaccination strategy this June for the first time in five years, a tactic that helped to reach the majority of children targeted, according to WHO.

Health officials in Pakistan say they want the both sides to conduct anti-polio drives simultaneously.

The Canadian Press. All rights reserved.

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White House says health insurance needs to fully cover condoms, other over-the-counter birth control

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WASHINGTON (AP) — Millions of people with private health insurance would be able to pick up over-the-counter methods like condoms, the “morning after” pill and birth control pills for free under a new rule the White House proposed on Monday.

Right now, health insurers must cover the cost of prescribed contraception, including prescription birth control or even condoms that doctors have issued a prescription for. But the new rule would expand that coverage, allowing millions of people on private health insurance to pick up free condoms, birth control pills, or “morning after” pills from local storefronts without a prescription.

The proposal comes days before Election Day, as Vice President Kamala Harris affixes her presidential campaign to a promise of expanding women’s health care access in the wake of the U.S. Supreme Court’s decision to undo nationwide abortion rights two years ago. Harris has sought to craft a distinct contrast from her Republican challenger, Donald Trump, who appointed some of the judges who issued that ruling.

“The proposed rule we announce today would expand access to birth control at no additional cost for millions of consumers,” Health and Human Services Secretary Xavier Becerra said in a statement. “Bottom line: women should have control over their personal health care decisions. And issuers and providers have an obligation to comply with the law.”

The emergency contraceptives that people on private insurance would be able to access without costs include levonorgestrel, a pill that needs to be taken immediately after sex to prevent pregnancy and is more commonly known by the brand name “Plan B.”

Without a doctor’s prescription, women may pay as much as $50 for a pack of the pills. And women who delay buying the medication in order to get a doctor’s prescription could jeopardize the pill’s effectiveness, since it is most likely to prevent a pregnancy within 72 hours after sex.

If implemented, the new rule would also require insurers to fully bear the cost of the once-a-day Opill, a new over-the-counter birth control pill that the U.S. Food and Drug Administration approved last year. A one-month supply of the pills costs $20.

Federal mandates for private health insurance to cover contraceptive care were first introduced with the Affordable Care Act, which required plans to pick up the cost of FDA-approved birth control that had been prescribed by a doctor as a preventative service.

The proposed rule would not impact those on Medicaid, the insurance program for the poorest Americans. States are largely left to design their own rules around Medicaid coverage for contraception, and few cover over-the-counter methods like Plan B or condoms.

The Canadian Press. All rights reserved.

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