Background Patients with rheumatoid arthritis (RA) are at high risk of developing cardiovascular disease (CVD) and may benefit from potent disease-modifying anti-inflammatory drugs such as biologics. Since diabetes mellitus (DM) is a major risk factor for CVD, RA patients with DM constitute a high CVD risk subgroup, calling for particular attention. However, there is a lack of knowledge on the comparative cardiovascular safety of different biologics in RA patients with DM.
Objectives To examine the comparative cardiovascular safety of abatacept versus TNF inhibitors in RA patients with and without DM.
Methods RA patients enrolled in both public (Medicare) and commercial (Truven MarketScan) health plans in the U.S. who newly initiated abatacept or TNF inhibitors were eligible. The primary outcome of interest was a composite CVD endpoint of myocardial infarction (MI), stroke/transient ischemic attack (TIA), and coronary revascularization. The secondary outcomes included each component of the composite CVD endpoint and heart failure (HF). After 1:1 propensity score (PS) matching between two exposure groups, Cox proportional hazard model was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for each outcome, comparing abatacept to TNF inhibitors. PS matching was separately done in subgroups with or without baseline DM in each database. PS-matched HRs from the two databases were pooled using an inverse variance–weighted fixed-effect model.
Results We identified 31,899 Medicare enrollees (6,107 new users of abatacept and 25,792 new users of TNF inhibitors) and 71,956 commercial enrollees (6,942 new users of abatacept and 65,464 new users of TNF inhibitors) with RA. After PS matching, 2,119 pairs with DM and 3,984 pairs without DM were identified in Medicare and 1,371 pairs with DM and 5565 pairs without DM in MarketScan. The PS matched HR (95% CI) for the composite CVD endpoint in the whole cohort was 0.81 (0.66–0.99) in Medicare and 0.95 (0.74–1.23) in MarketScan with a pooled HR (95% CI) of 0.86 (0.73–1.01). In the subgroup with DM, HR (95% CI) for composite CVD endpoint was 0.72 (0.53–0.99) in Medicare and 0.79 (0.50–1.25) in MarketScan with a pooled HR (95% CI) of 0.74 (0.57–0.96). In the subgroup without DM, HR (95% CI) was 0.88 (0.67–1.14) in Medicare and 1.03 (0.76–1.40) in MarketScan with a pooled HR (95% CI) of 0.94 (0.77–1.14). For secondary outcomes (Figure 1), the pooled HR (95% CI) was 0.77 (0.59–1.00) for MI and 0.74 (0.57–0.97) for coronary revascularization in the whole cohort. There was a trend toward a decreased risk, albeit statistically insignificant, for MI and coronary revascularization in each subgroup. There was no significant difference in the risk for stroke/TIA and HF.
Conclusions Among RA patients, abatacept may be associated with a reduced risk of coronary events compared to TNF inhibitors, particularly in patients with DM. The risk of HF was not different between these two groups.
Disclosure of Interest None declared