title: TNF-αAntagonist and Infection in Rheumatoid Arthritis.
abstract: BACKGROUND
  Anti-TNF treatment may increase infection risk, although this has been difficult to study because the timing of anti-TNF treatment is driven by disease activity, which may influence infection susceptibility leading to confounding that varies over time. We evaluated the association between anti-TNF initiation in rheumatoid arthritis (RA) patients on disease modifying anti-rheumatic drugs (DMARD) and infection using multiple approaches adjusting for time-varying confounding.
  
  
  METHODS
  383 anti-TNF-naïve RA patients on ≥1 non-biologic-DMARD at enrollment from the Brigham and Women's Rheumatoid Arthritis Sequential Study (BRASS) were followed up to two years. Pooled logistic regressions estimated the association between anti-TNF and infection by including time-varying covariates in the adjusted models and inverse probability treatment weighting (IPTW).
  
  
  RESULTS
  Adjustment for time-varying disease activity and other suspected confounders yielded non-statistically significant positive associations between anti-TNF start and infection regardless of analytic approach (RRmvar_adj= 2.1, 95% CI: 0.8 - 5.8).
  
  
  CONCLUSIONS
  Incorporating changing clinical status, and treatment indications and consequences, yielded consistently (though not significantly) elevated relative risks of infection associated with anti-TNF initiation. Due to limited statistical power, we cannot draw firm conclusions. However, we have illustrated multiple approaches adjusting for potential time-varying confounding in longitudinal studies and hope to replicate the approaches in larger studies.
authors.affiliation: Department of Epidemiology, Harvard School of Public Health, Boston, USA ; Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Julia F
authors.initials: JF
authors.lastname: Simard
authors.affiliation: Department of Epidemiology, Harvard School of Public Health, Boston, USA.
authors.forename: Murray A
authors.initials: MA
authors.lastname: Mittleman
authors.affiliation: Department of Medicine, Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, USA.
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Shadick
authors.affiliation: Department of Medicine, Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, USA.
authors.forename: Elizabeth W
authors.initials: EW
authors.lastname: Karlson
keywords: Anti-TNF; Infection; Inverse Probability Weighting; Rheumatoid Arthritis