Risk of Heart Failure in Patients Using TNF Inhibitors
Absolute Contraindications
- TNF antagonist therapy must be avoided in patients with severe (NYHA class III and IV) cardiac failure, as recommended by the British Journal of Dermatology, due to increased mortality and hospitalization rates 3, 5
- High-dose infliximab (10 mg/kg) was associated with increased mortality in severe heart failure patients, leading to premature trial discontinuation 1, 2
- Etanercept trials in severe CHF were terminated early due to lack of efficacy or failure to show benefit on CHF morbidity or mortality 2, 6
Risk in Mild-to-Moderate Heart Failure
- Obtain a screening echocardiogram before initiating TNF antagonist therapy in patients with well-compensated heart failure (NYHA class I and II) 3, 5
- Do not initiate TNF antagonist therapy if ejection fraction is <50% of normal in patients with well-compensated heart failure (NYHA class I and II) 3, 5
- Withdraw treatment immediately at the onset of new symptoms or worsening of pre-existing heart failure 1, 2, 3
Evidence of New-Onset Heart Failure
- 47 spontaneous FDA reports documented new-onset or worsening heart failure following infliximab or etanercept, with 50% of patients having no identifiable pre-existing risk factors for heart disease 1, 3, 7
- Median onset of symptoms was 3 months with infliximab and 8.5 months with etanercept 3, 7
- Complete resolution or substantial improvement occurred after drug withdrawal in younger patients (<50 years) 3, 7
Alternative Biologic Options for Patients with Heart Failure
- The American College of Rheumatology conditionally recommends IL-17 inhibitors or IL-12/23 inhibitors (ustekinumab) as preferred alternatives to TNF inhibitors in patients with heart failure 4