The literature shows a positive correlation between severity of RA and the risk of both non-Hodgkin’s lymphomas (NHL) and Hodgkin’s lymphoma (HL), and it is believed that immunological elements can trigger transformation of normal lymphocyte polyclonal population into lymphoproliferative disease.25,26 Severe RA has a higher risk of lymphoma than the general population. In general, the risk ratio for lymphoma in RA patients is 2.0, and the hazard ratio for lymphoma in RA patients receiving bDMARDs falls into the range of 2.3–5.9, which is not significantly different from RA patients receiving sDMARDs per EULAR safety recommendations.1,27 Per these summarized data, there is no clear evidence that RA lymphoma risks are increased by bDMARDs.
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Explore This IssueDecember 2017
Per new EULAR safety recommendations, the risk of melanoma may be slightly increased in patients receiving bDMARDs compared with sDMARDs with an adjusted HR of 1.5.1 However, a recent malignancy risk study conducted in Australian RA patients showed that melanoma risk was increased in both TNFi-treated and biologic-naive RA patients compared with the general population, with a standardized incidence ratio (SIR) of 2.72 and 2.03, respectively.28
An evaluation of the long-term risks and benefits of using bDMARDs suggests that bDMARDs have more statistically significant clinical benefits in the areas of total joint replacement and CVD risk in RA patients. Malignancy should not be a barrier for RA patients to receive bDMARDs, as long as patients are under close monitoring by both rheumatologists and oncologists. Based on current studies, bDMARDs showed significant value clinically, but work still needs to be done to show significant long-term economic value. Future studies should be designed to demonstrate comprehensive and clear clinical roles of bDMARDs in heterogenous diseases, such as CVD.
Nan Yang, PharmD, is a one-year postgraduate employed by Evergreen Pharmacy in West Allis, Wis.
Kurt Oelke, MD, is the clinical studies director at the Rheumatic Disease Center in Glendale, Wis.
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- Wolfe F, Zwillich SH. The long-term outcomes of rheumatoid arthritis: A 23-year prospective, longitudinal study of total joint replacement and its predictors in 1,600 patients with rheumatoid arthritis. Arthritis Rheum. 1998 Jun;41(6):1072–1082.
- Hekmat K, Jacobsson L, Nilsson JÅ, et al. Decrease in the incidence of total hip arthroplasties in patients with rheumatoid arthritis—results from a well defined population in south Sweden. Arthritis Res Ther. 2011 Apr 21;13(2):R67.
- David G, Tandon N, Waters HC, et al. Rheumatoid arthritis and joint replacement: Impact of biologics. Am J Pharm Benefits. 2014;6(6):256–264.
- Cordtz R, Hawley S, Prieto-Alhambra D, et al. Incidence of knee and hip replacements in rheumatoid arthritis patients following introduction of biological DMARDs: An interrupted time series analysis using nationwide health care registers [abstract 2017 OP0251]. EULAR 2017, Madrid.
- Hawley S, Cordtz R, Dreyer L, et al. The impact of biologic therapy introduction on hip and knee replacement among rheumatoid arthritis patients: An interrupted time series analysis using the clinical practice research datalink [abstract]. Arthritis Rheumatol. 2016;68(suppl 10)..
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- Sverre H, Ingvild O, Tor-Arne H, et al. Increased levels of lipoprotein(a) in RA patients with cardiovascular disease [abstract 1474]. Arthritis Rheumatol. 2016;68(suppl 10).
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- Desai RJ, Solomon DH, Schneeweiss S, et al. Tumor necrosis factor-α inhibitor use and the risk of incident hypertension in patients with rheumatoid arthritis. Epidemiology. 2016 May;27(3):414–422.
- Myasoedova E, Gabriel SE, Mattson E, et al. Decreased cardiovascular mortality in patients with incident RA in recent years: Dawn of a new era in cardiovascular disease in RA? J Rheumatol. 2017 Jun;44(6):732–739.
- AbbVie Inc. Product information: HUMIRA subcutaneous injection, adalimumab subcutaneous injection.
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