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Tumour necrosis factor inhibitor treatment and occurrence of anterior uveitis in ankylosing spondylitis: results from the Swedish biologics register
  1. Elisabeth Lie1,2,
  2. Ulf Lindström1,
  3. Tatiana Zverkova-Sandström1,
  4. Inge C Olsen2,
  5. Helena Forsblad-d'Elia3,
  6. Johan Askling4,
  7. Meliha C Kapetanovic5,
  8. Lars Erik Kristensen5,6,
  9. Lennart T H Jacobsson1
  1. 1 Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
  2. 2 Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  3. 3 Department of Public Health and Clinical Medicine, Rheumatology, Umeå University, Umeå, Sweden
  4. 4 Clinical Epidemiology Unit & Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
  5. 5 Section of Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
  6. 6 Musculoskeletal Statistics Unit, The Parker Institute, Department of Rheumatology, Copenhagen University Hospital, Copenhagen, Denmark
  1. Correspondence to Dr Ulf Lindström, Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Guldhedsgatan 10A, Gothenburg 405 30, Sweden; ulf.lindstrom{at}


Objectives Tumour necrosis factor-α inhibitor (TNFi) treatment has been shown to reduce the rates of anterior uveitis (AU) in patients with ankylosing spondylitis (AS). Our objective was to compare the effect of adalimumab (ADA), etanercept (ETN) and infliximab (IFX) on AU occurrence in AS, using real-world data.

Methods Patients with AS starting ADA, ETN or IFX as their first TNFi from January 2003 to December 2010 were extracted from the Swedish Rheumatology Quality Register. AU rates, based on visits to an ophthalmologist with International Classification of Diseases 10 codes for AU, were obtained by linkage to the Swedish National Patient Register. For each TNFi, AU rates 2 years before TNFi start and for the first 2 years on TNFi treatment were compared. In the subgroup of patients who were AU-free during the 2 years before TNFi start, we also compared the risk of a first AU event.

Results 1365 patients with AS were included (406 ADA, 354 ETN, 605 IFX). Compared with pretreatment rates, we noted a reduction in overall AU rates for ADA and IFX, and an increase for ETN. The adjusted HRs for AU in 1127 patients who were free of AU in the last 2 years before TNFi start were significantly higher for ETN versus ADA (HR: 3.86 95% CI 1.85 to 8.06) and ETN versus IFX (HR: 1.99, 95% CI 1.23 to 3.22), while the HR for IFX versus ADA was not statistically significant.

Conclusions The results suggest differences in effect on AU risk between ADA, ETN and IFX, with a clear advantage for ADA/IFX over ETN.

  • Ankylosing Spondylitis
  • Anti-TNF
  • Treatment

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  • Handling editor Hans WJ Bijlsma

  • EL and UL co-first authors

  • EL and UL contributed equally

  • Contributors All authors have contributed substantially in the process of completing this study and had full access to the data, specified as follows: Conception of the study: EL and LTHJ. Designing the study: All authors. Aggregation of data TZ-S. Statistical analysis TZ-S, ICO, EL and UL. Interpretation of data all authors. Drafting and revising, final approval and agreement to be accountable: all authors.

  • Funding The study received funding from the following sources, which did not influence either the design of the study, the collection and analysis of the data or the preparation of the manuscript: The Swedish Research Council, Gothenburg University, the Stockholm County Council (ALF), The Swedish National Rheumatism Association, the Swedish COMBINE public-private research programme, the Swedish Cancer Society, the EU-IMI BT Cure project and the Swedish Foundation for Strategic Research. ARTIS has entered into agreements with MAH for rheumatology biologicals (AbbVie, BMS, Merck, Pfizer, Roche, Samsung, UCB) regarding the safety surveillance of these drugs. All authors state their complete independence from the funders, with regard to this study.

  • Competing interests EL has received personal fees from AbbVie, Bristol-Myers Squibb, Hospira, Pfizer and UCB. LEK has received fees for speaking and consultancy from Pfizer, UCB, Roche, AbbVie, BMS, Novartis, Eli Lilly, Celgene, Biogen and MSD. LTHJ has received Advisory Board fees from AbbVie, Celegen, MSD, Novartis and UCB. JA has participated in advisory boards arranged by Lilly, AstraZeneca and Novartis but not received any personal remuneration.

  • Ethics approval The regional ethical committee in Stockholm, Sweden, approved the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Technical appendix and statistical codes are available from the corresponding author at request. Consent was not obtained but the presented data are anonymised and risk of identification is low.