title: Risk of elevated liver enzymes associated with TNF inhibitor utilisation in patients with rheumatoid arthritis.
abstract: OBJECTIVE
  Liver function test (LFT) elevations are reported with the use of tumour necrosis factor inhibitors (TNF-Is). The aim of this study was to compare LFT elevations in patients with rheumatoid arthritis receiving adalimumab (ADA), etanercept (ETN) or infliximab (INF) enrolled in the Consortium of Rheumatology Researchers of North America from October 2001 to March 2007.
  
  
  METHODS
  Alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) levels >1x upper limit of normal (ULN) were considered elevations and ALT/AST levels >2x ULN were considered abnormalities. Treatments included TNF-Is, methotrexate (MTX), leflunomide and other disease-modifying antirheumatic agents (DMARDs). Patients were censored after their first LFT elevation. Three analytical models were evaluated: (1) individual TNF-I vs non-biological DMARDs (primary model); (2) individual TNF-I plus MTX vs MTX monotherapy; and (3) limited to new users of individual TNF-I vs non-biological DMARDs. ORs for LFT elevations were estimated using generalised estimating equation logistic regression.
  
  
  RESULTS
  6861 patients (ADA: 849; ETN: 1383; INF: 1449) with 22 522 determinations were analysed. LFT elevations >1x ULN with TNF-I use were seen in 5.9% of AST/ALT determinations and abnormalities >2x ULN in 0.77%. In the primary model the adjusted ORs for LFT elevations >1x ULN were ADA 1.35 (95% CI 1.09 to 1.66), ETN 1.00 (95% CI 0.83 to 1.21) and INF 1.58 (95% CI 1.35 to 1.86). For 2x ULN, adjusted ORs were ADA 1.72 (95% CI 0.99 to 3.01), ETN 1.10 (95% CI 0.64 to 1.88) and INF 2.40 (95% CI 1.53 to 3.76). Similar results were obtained in other models.
  
  
  CONCLUSIONS
  The overall incidence of LFT elevations >1x ULN with TNF-I use was uncommon and abnormalities >2x ULN were rarely observed. Significant differences were most consistently observed with INF, less commonly with ADA and were not observed with ETN compared with comparator DMARDs.
authors.affiliation: Stanford University, Palo Alto, CA, USA.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Sokolove
authors.forename: Vibeke
authors.initials: V
authors.lastname: Strand
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Greenberg
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Curtis
authors.forename: Arthur
authors.initials: A
authors.lastname: Kavanaugh
authors.forename: Joel M
authors.initials: JM
authors.lastname: Kremer
authors.forename: Alina
authors.initials: A
authors.lastname: Anofrei
authors.forename: George
authors.initials: G
authors.lastname: Reed
authors.forename: Leonard
authors.initials: L
authors.lastname: Calabrese
authors.forename: Michele
authors.initials: M
authors.lastname: Hooper
authors.forename: Scott
authors.initials: S
authors.lastname: Baumgartner
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Furst
mesh_terms: D000068879:Adalimumab; D000328:Adult; D000368:Aged; D000410:Alanine Transaminase / Q000097:blood; D000911:Antibodies, Monoclonal / Q000009:adverse effects; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001219:Aspartate Aminotransferases / Q000097:blood; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology*; D004359:Drug Therapy, Combination; D004812:Epidemiologic Methods; D000068800:Etanercept; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000009:adverse effects; D007166:Immunosuppressive Agents / Q000009:adverse effects; D000069285:Infliximab; D008111:Liver Function Tests; D008297:Male; D008727:Methotrexate / Q000009:adverse effects; D008875:Middle Aged; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase; D000068879:Adalimumab; D000068800:Etanercept; D008727:Methotrexate