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.
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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TORONTO – Health Canada has authorized Moderna’s updated COVID-19 vaccine that protects against currently circulating variants of the virus.
The mRNA vaccine, called Spikevax, has been reformulated to target the KP.2 subvariant of Omicron.
It will replace the previous version of the vaccine that was released a year ago, which targeted the XBB.1.5 subvariant of Omicron.
Health Canada recently asked provinces and territories to get rid of their older COVID-19 vaccines to ensure the most current vaccine will be used during this fall’s respiratory virus season.
Health Canada is also reviewing two other updated COVID-19 vaccines but has not yet authorized them.
They are Pfizer’s Comirnaty, which is also an mRNA vaccine, as well as Novavax’s protein-based vaccine.
This report by The Canadian Press was first published Sept. 17, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
VANCOUVER – Mayors and other leaders from several British Columbia communities say the provincial and federal governments need to take “immediate action” to tackle mental health and public safety issues that have reached crisis levels.
Vancouver Mayor Ken Sim says it’s become “abundantly clear” that mental health and addiction issues and public safety have caused crises that are “gripping” Vancouver, and he and other politicians, First Nations leaders and law enforcement officials are pleading for federal and provincial help.
In a letter to Prime Minister Justin Trudeau and Premier David Eby, mayors say there are “three critical fronts” that require action including “mandatory care” for people with severe mental health and addiction issues.
The letter says senior governments also need to bring in “meaningful bail reform” for repeat offenders, and the federal government must improve policing at Metro Vancouver ports to stop illicit drugs from coming in and stolen vehicles from being exported.
Sim says the “current system” has failed British Columbians, and the number of people dealing with severe mental health and addiction issues due to lack of proper care has “reached a critical point.”
Vancouver Police Chief Adam Palmer says repeat violent offenders are too often released on bail due to a “revolving door of justice,” and a new approach is needed to deal with mentally ill people who “pose a serious and immediate danger to themselves and others.”
This report by The Canadian Press was first published Sept. 16, 2024
The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
