Should I avoid Tumor Necrosis Factor inhibitors (TNFi) in a patient with diastolic dysfunction and shortness of breath (SOB) but not congestive heart failure (CHF)?

From the Guidelines

TNF inhibitors can generally be used in patients with diastolic dysfunction and shortness of breath without congestive heart failure, but caution is warranted. These medications (including adalimumab, etanercept, infliximab, certolizumab, and golimumab) do not typically worsen diastolic dysfunction when CHF is absent, as suggested by studies such as 1. However, careful baseline cardiac evaluation is recommended before starting treatment, including assessment of ejection fraction and functional status, as outlined in guidelines like 1. Regular monitoring of cardiac symptoms during treatment is important, especially in the first few months. If the patient has risk factors for heart failure (such as hypertension, coronary artery disease, or diabetes), more frequent cardiac monitoring may be necessary.

Key Considerations

• TNF inhibitors are contraindicated in patients with moderate to severe heart failure (NYHA Class III-IV) and should be used cautiously in those with mild heart failure (NYHA Class I-II) 1.
• The concern stems from TNF inhibitors' potential to worsen existing heart failure through direct myocardial effects, though the mechanism isn't fully understood.
• If shortness of breath worsens during treatment, prompt cardiac evaluation is essential to rule out developing heart failure.
• Diastolic dysfunction, as discussed in 1, is a condition where the heart's ability to relax and fill during diastole is impaired, and it can lead to heart failure with preserved ejection fraction.

Monitoring and Management

• Baseline cardiac evaluation should include assessment of ejection fraction and functional status.
• Regular monitoring of cardiac symptoms, such as shortness of breath, fatigue, and exercise intolerance, is crucial during treatment.
• Patients with risk factors for heart failure require more frequent cardiac monitoring.
• Management of heart failure with preserved ejection fraction, as outlined in 1, includes controlling systolic and diastolic hypertension, ventricular rate in patients with atrial fibrillation, and using diuretics to control pulmonary congestion and peripheral edema.

From the FDA Drug Label

Cases of worsening congestive heart failure (CHF) and new onset CHF have been reported with TNF blockers. ... Exercise caution when using HUMIRA in patients who have heart failure and monitor them carefully.

Avoiding TNFi in patients with diastolic dysfunction and SOB is recommended due to the potential risk of worsening heart failure. Although the patient does not have congestive heart failure (CHF), the presence of diastolic dysfunction and shortness of breath (SOB) suggests underlying cardiac issues.

• The FDA drug label warns about the risk of worsening CHF and new onset CHF with TNF blockers.
• It is recommended to exercise caution when using TNF blockers, including adalimumab, in patients with heart failure.
• Given the potential risks, it is prudent to avoid TNFi in this patient to minimize the risk of exacerbating their cardiac condition 2.

From the Research

Diastolic Dysfunction and TNFi

• Diastolic dysfunction is a condition where the heart's ability to relax and fill with blood is impaired, which can lead to heart failure 3, 4, 5.
• Tumor Necrosis Factor inhibitors (TNFi) are a class of drugs used to treat autoimmune diseases such as rheumatoid arthritis, Crohn's disease, and psoriasis 6, 7.

Risks of TNFi in Patients with Diastolic Dysfunction

• There is evidence to suggest that TNFi may increase the risk of congestive heart failure (CHF) in patients with pre-existing heart conditions 6.
• However, it is not clear if TNFi would exacerbate diastolic dysfunction in patients without CHF [no direct evidence].
• Patients with diastolic dysfunction and shortness of breath (SOB) may be at increased risk of developing CHF, and the use of TNFi in these patients should be carefully considered 3, 4, 5.

Considerations for Treatment

• The decision to use TNFi in a patient with diastolic dysfunction and SOB should be based on a careful evaluation of the potential benefits and risks 6, 7.
• Clinicians should be aware of the potential side effects of TNFi, including the risk of CHF, and monitor patients closely for signs of worsening heart function 6.