Characterize prevalence of demyelinating disease with TNF? inhibitor exposure

Tumor necrosis factor-alpha (TNF?) inhibitors are used to treat many autoimmune conditions. However, TNF blockade has been associated with worsening of multiple sclerosis (MS) and the development of secondary demyelinating disease. With MS incidence rising, understanding iatrogenic causes and risk stratification for TNF? therapy is paramount. 

We performed a single-system retrospective cohort study. Adult patients (≥ 18 years old) exposed to FDA-approved TNF? inhibitors from 2007-2017 in the Yale New Haven Hospital system were identified. Of these, patients with subsequent MRI brain and spinal cord imaging were identified. Individual chart reviews reviewed demographics, TNF? agent, social and medical history, family history, indications and results of MRI imaging and subsequent TNF? medication changes. 

Preliminary results are reported with final results to be presented at the conference. 428 total patients were identified to have both TNF? exposure and CNS imaging. 73% of patients had exposure to TNF? prior to MRI imaging, 65% of which were female and 35% of which were male. 76% of patients were White/Caucasian, 11% were Black/African American and the remainder were Asian or refused. 86% of patients had a diagnosed autoimmune disease and the remainder received TNF blockade for other indications such as chemotherapy side effects. Of those with exposure prior to MRI, 21% had normal MRIs, 42% had nonspecific MRI findings, 4% had white matter changes concerning for demyelinating disease, 2% had confluent white matter changes and 31% had other abnormal findings that was not thought to be related to TNF blockade.

TNF blockade and risk of secondary demyelinating disease may not be as common a complication as previously thought. Most patients in this cohort had either normal or non-specific MRI findings despite neurological complaints. However, the risk remains and further risk stratification parameters need to be identified.