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A Practical Approach to the Use of Conventional Synthetic, Biologic and Targeted Synthetic Disease Modifying Anti-Rheumatic Drugs for the Treatment of Inflammatory Arthritis in Patients with a History of Malignancy

  • Rheumatoid Arthritis (L Moreland, Section Editor)
  • Published:
Current Rheumatology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) have been used in the treatment of inflammatory arthritis (IA) for many years. More recently, biologic (bDMARDs) and targeted synthetic (tsDMARDs) DMARDs have further improved treatment. Due to increased patient longevity and effective oncology treatment, rheumatologists often encounter patients with IA and previous malignancy. The immunosuppressive effect of DMARDs causes concern regarding impaired tumour surveillance with a potential increased risk of malignancy. We reviewed the literature regarding the risk of malignancy in patients on cs-/b-/tsDMARDS and sought to provide practical advice regarding use of these drugs in patients with previous malignancy.

Recent Findings

Data from randomised controlled trials is limited as patients with pre-existing malignancy are often excluded. Reassuringly, an increasing range of “real world” data from various national b/tsDMARD registries has not provided a convincing signal that these drugs increase tumour recurrence. Nevertheless, awareness of, and adherence to, national screening guidelines for malignancy is important.

Summary

Given the improvement in quality of life achieved with these novel and well-tolerated therapeutic agents, the benefit/risk profile remains overwhelmingly favourable in most patients.

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Abbreviations

ABA:

abatacept

ACR:

American College of Rheumatology

ARAD:

Australian Rheumatology Association Database

ARTIS:

Anti-Rheumatic Therapies in Sweden

AZA:

azathioprine

BCC:

basal cell cancer

bDMARDs:

biologic disease modifying anti-rheumatic drugs

BSRBR:

British Society of Rheumatology Biologics Register

CI:

confidence interval

CORRONA:

Consortium of Rheumatology Researchers of North America

CIN:

cervical intraepithelial neoplasia

CSA:

cyclosporin A

csDMARDs:

conventional synthetic disease modifying anti-rheumatic drugs

CYC:

cyclophosphamide

HL:

Hodgkin’s lymphoma

HCQ:

hydroxychloroquine

HR:

hazard ratio

IA:

inflammatory arthritis

IBD:

inflammatory bowel disease

IV:

intravenous

LEF:

leflunomide

LPD:

lymphoproliferative disorders

LTE:

long-term extension

MTX:

methotrexate

NHL:

non-Hodgkin’s lymphoma

NMSC:

non-melanomatous skin cancer

p-y:

patient-years

RABBIT:

Rheumatoid Arthritis Observation of Biologic Therapies

RCT:

randomised controlled trial

RR:

relative risk

RTX:

rituximab

SCC:

squamous cell cancer

SIR:

standardised incidence ratio

SMR:

standardised mortality ratio

SpA:

spondyloarthritis

SSZ:

sulfasalazine

TCZ:

tocilizumab

TFN:

tofacitinib

TNFi:

tumour necrosis factor inhibitor

TP:

thiopurine

tsDMARD:

targeted synthetic disease modifying anti-rheumatic drugs

US:

United States

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All authors read and approved the final manuscript (see the “Methods” section for explanation).

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Correspondence to Peter K. K. Wong.

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Conflict of Interest

Dr. Kodali reports non-financial support from Bristol-Myers Squibb Australia (BMSA), non-financial support from Amgen, personal fees and non-financial support from Janssen-Cilag, non-financial support from Abbvie, non-financial support from Pfizer, non-financial support from Roche, outside the submitted work.

Dr. Chong reports research funding from Novartis, Pharmacyclics, Bayer, Bristol Myers Squibb, Merck Serono, Hutchison Medipharma and Pfizer, outside the submitted work.

Dr. Marabani reports personal fees from Abbvie, personal fees from BMS, personal fees from MSD, personal fees from Pfizer, personal fees from NPS MedicinesWise, personal fees from Sanofi, personal fees from Janssen, personal fees from Lilly, personal fees from Novartis, outside the submitted work.

Peter KK Wong, Hanish Bagga, Claire Barrett, Patrick Hanrahan, H. Miles Prince, John Riordan, Phillip Swarbrick, Ray White and Laurel Young declare that they have no conflicts of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Rheumatoid Arthritis

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Wong, P.K.K., Bagga, H., Barrett, C. et al. A Practical Approach to the Use of Conventional Synthetic, Biologic and Targeted Synthetic Disease Modifying Anti-Rheumatic Drugs for the Treatment of Inflammatory Arthritis in Patients with a History of Malignancy. Curr Rheumatol Rep 20, 64 (2018). https://doi.org/10.1007/s11926-018-0774-9

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