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Tumour necrosis factor inhibitor exposure and radiographic outcomes in Veterans with rheumatoid arthritis: a longitudinal cohort study


Cannon GW1,2, Erickson AR3, Teng CC1,4, Huynh T1,4, Austin S1,5, Wade SW6, Stolshek BS7, Collier DH8, Mutebi A7, Sauer BC1,4. Rheumatol Adv Pract. 2019 May 28;3(1):rkz015. doi: 10.1093/rap/rkz015. eCollection 2019.

Author Information

1 Salt Lake City VA Medical Center, University of Utah, Salt Lake City, UT, USA.

2 Division of Rheumatology, University of Utah, Salt Lake City, UT, USA.

3 VA Nebraska-Western Iowa Health Care System and Division of Rheumatology, University of Nebraska Medical Center, Omaha, NE, USA.

4 Division of Epidemiology, University of Utah, Salt Lake City, UT, USA.

5 Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.

6 Wade Outcomes Research and Consulting, Salt Lake City, UT, USA.

7 Global Health Economics, Amgen Inc., USA.

8 Clinical Development, Amgen Inc., Thousand Oaks, CA, USA.



The aim was to estimate the impact of TNF inhibitor (TNFi) exposure on radiographic disease progression in US Veterans with RA during the first year after initiating therapy.


This historical longitudinal cohort design used clinical and claims data to evaluate radiographic progression after initiation of TNFi. US Veterans with RA initiating TNFi treatment (index date), ≥ 6 months pre-index and ≥ 12 months post-index VA enrolment/activity, and initial (6 months pre-index to 30 days post-index) and follow-up (10-18 months post-index) bilateral hand radiographs were eligible. The cumulative TNFi exposure and change in modified Sharp score (MSS) between initial and follow-up radiographs were calculated. The percentage of patients with clinically meaningful change in MSS (≥ 5) for each month of exposure was assessed using a longitudinal marginal structural model with inverse probability of treatment weights. Mean values and CIs were generated using 1000 bootstrapped samples.


For 246 eligible patients, the mean (s.d.) age was 58 (11) years; 81% were male. The mean (s.d.) initial MSS was 19.6 (33.4) (range 0-214). The mean change (s.d.) in MSS was 0.3 (3.6) (median 0, range -19 to 22). Patients with the greatest exposure had the least radiographic progression for both crude and adjusted model analyses. Adjusted rates of MSS change ≥ 5 points (95% CI) were 10.6% (9.8%, 11.4%) for patients with 3 months of exposure compared with 5.4% (5.1%, 5.7%) for patients with 12 months of exposure.


One-year changes in radiographic progression were small. Patients with the greatest cumulative TNFi exposure experienced the least progression.