title: Comparative effects of biologics on cardiovascular risk among older patients with rheumatoid arthritis.
abstract: OBJECTIVE
  To compare the coronary heart disease risk among patients with rheumatoid arthritis (RA) initiating common biologic disease-modifying antirheumatic drugs of different mechanisms.
  
  
  METHODS
  We conducted a retrospective cohort study of patients with RA enrolled in Medicare, a public health plan covering >90% of US residents 65 years or older, from 2006 to 2012 who (1) initiated a biologic, (2) had complete medical and pharmacy coverage for at least 12 months before biologic initiation and (3) were free of coronary heart disease at the time of initiation. We compared the incidence rates (IRs) of (1) acute myocardial infarction (AMI) and (2) a composite outcome of AMI or coronary revascularisation and used multivariable adjusted Cox regression models to examine the associations between the type of biologic and the two outcomes.
  
  
  RESULTS
  We identified 47 193 eligible patients with RA with mean age 64 (SD 13) years; 85% were women. Crude IRs for AMI ranged from 5.7 to 8.8 cases per 1000 person-years (PYs). AMI risk was significantly elevated among antitumour necrosis factor (anti-TNF) initiators overall (adjusted HR (aHR) 1.3; 95% CI 1.0 to 1.6) and individually among etanercept (aHR 1.3; 95% CI 1.0 to 1.8) and infliximab (aHR 1.3; 95% CI 1.0 to 1.6) compared with abatacept initiators. Crude IRs for the composite outcome ranged from 7.6 to 14.5 per 1000 PYs. Tocilizumab initiators were at reduced risk of the composite outcome compared with abatacept initiators (aHR 0.64, 95% CI 0.41 to 0.99).
  
  
  CONCLUSIONS
  Findings from this observational study of patients with RA suggested that anti-TNF biologics may be associated with higher AMI risk compared with abatacept.
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Jie
authors.initials: J
authors.lastname: Zhang
authors.affiliation: Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Fenglong
authors.initials: F
authors.lastname: Xie
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Huifeng
authors.initials: H
authors.lastname: Yun
authors.affiliation: Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Lang
authors.initials: L
authors.lastname: Chen
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Muntner
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Emily B
authors.initials: EB
authors.lastname: Levitan
authors.affiliation: Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Monika M
authors.initials: MM
authors.lastname: Safford
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Shia T
authors.initials: ST
authors.lastname: Kent
authors.affiliation: Division of Gastroenterology, Center for Clinical Epidemiology and Biostatistics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Mark T
authors.initials: MT
authors.lastname: Osterman
authors.affiliation: Division of Gastroenterology, Center for Clinical Epidemiology and Biostatistics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: James D
authors.initials: JD
authors.lastname: Lewis
authors.affiliation: Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Saag
authors.affiliation: Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA Medicine Service, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, New York, USA.
authors.forename: Jasvinder A
authors.initials: JA
authors.lastname: Singh
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Curtis
mesh_terms: D000069594:Abatacept / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy*; D001688:Biological Products / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology*; D000068800:Etanercept / Q000627:therapeutic use; D005260:Female; D006801:Humans; D015994:Incidence; D000069285:Infliximab / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D014481:United States / Q000453:epidemiology
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha; D000069594:Abatacept; D000069285:Infliximab; C502936:tocilizumab; D000068800:Etanercept
keywords: Cardiovascular Disease; DMARDs (biologic); Rheumatoid Arthritis