Background/Purpose Biologic drugs including anti-TNF agents have been used in the treatment of secondary amyloidosis, however, there is no controlled study concerning the efficacy of therapy. In this study, we retrospectively analyzed the clinical features and outcome of RA and AS patients with clinically symptomatic secondary amyloidosis who were treated with any of the biologic agents in various rheumatology centers in Turkey. 

Methods The hospital files in 10 university hospitals were examined to determine the presence of clinically apparent amyloidosis in RA and AS. Data concerning the clinical features, extraarticular involvement and biologic and other treatment response were obtained from hospital records. 

Results

27 RA (17F, 10M, mean age: 52.2), 42 AS (11F, 31M, mean age: 45.6) patients were included. Rheumatoid factor (RF) was positive in 24 (88.9%) RA patients. In 25 RA patients, the initial presentation of amyloidosis was with proteinuria; one had hematuria; and one patient prsented with renal dysfunction. Eight patients with proteinüria had also renal dysfunction.

The disease duration of RA patients before amyloidosis was 127.9 months; the duration of biologic therapy was 47.9 months. The first-line therapy was TNF-blockers in 21 RA patients; rituximab and abatacept in 2; and tociluzumab in one. Second-line biologicals were used because of side effects in 1 patient; and because of nonefficacy in 8 (2 TNF blocker, 4 rituximab, 2 tocilizumab, 1 abatacept). Third-line therapy was given to 4 patients.Renal function and/or proteinuria improved in 7 patients; however, they got worse in 7; and remained stable in 13. When patients who improved were compared to others, it was seen that there were more females (100% vs. 50%, p=0.026); and significantly longer duration of biologic therapy in this group. 2 patients using biologics developed tuberculosis; 3 patients died during follow-up because of nondrug-related causes. Renal replacement therapy was needed in 5 RA patients.  28 AS patients presented with proteinuria, 2 with hematuria, and 4 with isolated renal dysfunction. At the time of diagnosis for amyloidosis, 13 patients had also renal dysfunction. The disease duration of RA patients before amyloidosis was 101.2 months. All had been given anti-TNF agents as first-line therapy (infliximab in 13; etanercept in 19; adalimumab in 7; golimumab in 3 patients). 10 patients were switched to a second anti-TNF (because of serious side effects in 2 and nonefficacy in 8). Proteinuria and/or renal functions improved in 11 cases, got worse in 14, and remained stable in 9 after anti-TNF therapy. The results could not be evaluated in 8 patients. Initial CRP levels of patients who had any kind of improvement with anti-TNF therapy were significantly higher than others (p=0.007). There was requirement for renal replacement therapy in 11 AS patients. 

Conclusion Amyloidosis develops in RA and AS nearly 10 years after diagnosis; and it generally presents with proteiuria and/or renal dysfunction. In RA, the response to biologics was associated with a longer response to biologics and female sex. In AS patients, having a high CRP at the time of diagnosis of amyloidosis was associated with response to anti-TNF agents.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/are-biologic-agents-effective-on-the-treatment-of-secondary-amyloidosis-a-multicenter-report-on-turkish-rheumatoid-arthritis-and-ankylosing-spondylitis-patients/