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. 2025 Jul 11;9(1):88.
doi: 10.1186/s41927-025-00529-4.

The relationship between lifestyle factors and outcome of treatment with TNFα inhibitors in axial spondyloarthritis - results from 14 European countries

Gareth T Jones  1 , Ovidiu Rotariu  2 , Ross MacDonald  2 , Brigitte Michelsen  3   4   5 , Bente Glintborg  5   6 , Irene van der Horst-Bruinsma  7 , Bjorn Gudbjornsson  8   9 , Arni Jon Geirsson  10 , Heikki Relas  11 , Pia Isomäki  12   13 , Jakub Závada  14   15 , Karel Pavelka  14   15 , Ziga Rotar  16   17 , Matija Tomšič  16   17 , Michael J Nissen  18 , Adrian Ciurea  19 , Catalin Codreanu  20 , Johan K Wallman  21   22 , Eirik Klami Kristianslund  3 , Simon Horskjaer Rasmussen  5 , Lykke Midtbøll Ørnbjerg  5 , Maria José Santos  23   24 , Mikkel Østergaard  5   6 , Merete Lund Hetland  5   6 , Gary J Macfarlane  2
Affiliations

The relationship between lifestyle factors and outcome of treatment with TNFα inhibitors in axial spondyloarthritis - results from 14 European countries

Gareth T Jones et al. BMC Rheumatol. .

Abstract
in English, French

Objectives: To quantify the influence of lifestyle factors on tumour necrosis factor inhibitor (TNFi) treatment response, in axial spondyloarthritis (axSpA).

Methods: Data on biologics-naïve adults with axSpA were captured from European rheumatology registries. Information on lifestyle factors (smoking, overweight/obesity, and/or alcohol consumption) were identified ± 30 days of commencing their first TNFi. Treatment response (BASDAI-50, ASDAS or ASAS response criteria) was determined at 3 and 12 months. In separate models, the relationship between treatment response and baseline smoking, BMI and alcohol was assessed using logistic regression, adjusted for age, sex, country, calendar year of treatment initiation, disease duration and baseline disease activity.

Results: From 14 registries, 14,885 patients were included. Of those with available data, 29% were current smokers, 49% current drinkers, 37% were overweight and 21% were obese. At 12 months, smokers were less likely to achieve BASDAI-50 treatment response compared to non-smokers (adjusted odds ratio: 0.77; 95%CI: 0.68-0.86). A similar effect was observed among overweight (0.76; 0.66-0.87) or obese patients (0.53; 0.45-0.63). In contrast, alcohol drinkers experienced a seemingly beneficial effect (1.47; 1.16-1.87). These associations were also observed with other measures of treatment response and were robust to further adjustment for clinical characteristics.

Conclusion: Smoking and high BMI decrease the odds of bDMARD treatment success in axSpA. Rheumatologists should consider referral to smoking cessation and/or weight management interventions at the time of commencing therapy, to enhance treatment response. The relationship between alcohol and treatment response is unlikely to be causal and warrants further investigation.

What is already known about this subject? It has been shown that adverse lifestyle factors (smoking, high body mass index, alcohol consumption) are associated with poorer outcomes in axial spondyloarthritis, but there are no robust estimates that quantify the impact on anti-TNF treatment response. What does this study add? Our findings, pooling data from 14 national registries, demonstrate that patients who smoke experience a 20–25% decrease in the likelihood of meeting treatment response criteria, 12 months after commencing their first TNF inhibitor, an effect that was consistent across multiple outcome measures. Overweight/obese patients experience a 50% decrease in the odds of meeting such treatment criteria. For alcohol consumption, results were reversed, with current alcohol-users more likely to experience positive outcomes. This result was not supported by sensitivity analysis imputing missing values, and thus warrants further investigation. How might this impact on clinical practice or future developments? This paper quantifies the deleterious effect of smoking and obesity on the likelihood of treatment response in axial spondyloarthritis. As an adjunct to pharmacological management, lifestyle interventions might be considered as a way of optimising patient outcomes.

Keywords: Alcohol; Axial spondylarthritis; Body mass index; Lifestyle; Smoking.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The current study (secondary data analysis) did not require ethical approval. However, individual registries were was approved by the respective national Research Ethical Committees and Data Protection Agencies according to legal regulatory requirements in individual countries, and were performed in accordance with the Declaration of Helsinki. Consent for publication: All authors have approved the final manuscript and consent to publication. Competing interests: GTJ: Research grants (paid to employer) from AbbVie, Pfizer, UCB, Amgen, GSK; and speaker fee from Janssen. BM: Research grant (paid to employer) from Novartis. BGl: Research grants from Pfizer, AbbVie, BMS. IvdHB: Research grants from AbbVie, Pfizer, MSD and UCB, and honoraria/speakers fee from Novartis, BMS, Lilly, AbbVie, MSD, Pfizer and UCB. BGu: Speaker and consultancy fees from Amgen and Novartis. HR: Consulting and/or speaking fees from AbbVie, Celgene, Pfizer, UCB, and Viatris. PI: Research grant from Pfizer, speaker and consultancy fees from AbbVie, Eli Lilly, Galapagos, Pfizer, Roche and Vifor Pharma. JZ: Speaker and consulting fees from AbbVie, Eli Lilly, Sandoz, Novartis, Egis, UCB. KP: Speaker and consulting fees from Pfizer, MSD, BMS, UCB, Amgen, Egis, Roche, AbbVie. ZR: Speaker and consultancy fees from AbbVie, Amgen, Novartis, Pfizer, Eli Lilly, Lek-Sandoz, Biogen, MSD, Medis, Janssen. MT: Speaker and consultancy fees from AbbVie, Amgen, Biogen, Boehringer-Ingelheim, Eli Lilly, Janssen, Lek-Sandoz, Medis, MSD, Novartis, Pfizer. MJN: Speaker and consultancy fees from AbbVie, Novartis, Pfizer, Eli Lilly, and Janssen. AC: Speaker and/or consultancy fees from AbbVie, MSD, and Novartis. CC: Speaker and consultancy fees from AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis, Pfizer. JKW: Consultant of AbbVie, Amgen, Celgene, Eli Lilly, Novartis; and Research support from AbbVie, Amgen, Eli Lilly, Novartis, Pfizer. SHR: Research grant from Novartis. LMØ: Research grant from Novartis. MJS: Speaker fees from AbbVie, AstraZeneca, Janssen, Lilly, Novartis and Pfizer. MØ: Research grants from AbbVie, BMS, Merck and Novartis, and speaker and/or consultancy fees from AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB. MLH: Research grants from AbbVie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Medac, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis. GJM: Research grants (paid to employer) from AbbVie, Pfizer, UCB, Amgen, GSK. Authors not listed above have no conflict of interest to declare. In Denmark (DANBIO) ethical approval not required for registry studies [komitelovens § 14, stk. 2, www.nvk.dk ], and in Iceland (ICEBIO) it is possible to receive selected pre-defined data from registers for use in epidemiological studies with prior approval from the National Bioethics Committee and Data Protective Authorities without informed consent from the individual patient. In these cases, no personal identifiers are delivered to the researchers. For all other countries, informed consent to participate was obtained from all of the participants, prior to inclusion in the individual registries.

References

    1. van der Heijde D, Ramiro S, Landewé R, Baraliakos X, Van den Bosch F, Sepriano A, Regel A, Ciurea A, Dagfinrud H, Dougados M, van Gaalen F, Géher P, van der Horst-Bruinsma I, Inman RD, Jongkees M, Kiltz U, Kvien TK, Machado PM, Marzo-Ortega H, Molto A, Navarro-Compàn V, Ozgocmen S, Pimentel-Santos FM, Reveille J, Rudwaleit M, Sieper J, Sampaio-Barros P, Wiek D, Braun J. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76:978–91. - PubMed
    1. Zhao SS, Jones GT, Macfarlane GJ, Hughes DM, Dean LE, Moots RJ, Goodson NJ. Associations between smoking and extra-axial manifestations and disease severity in axial spondyloarthritis: results from the BSR biologics register for ankylosing spondylitis (BSRBR-AS). Rheumatology (Oxford). 2019;58:811–9. - PubMed
    1. Glintborg B, Højgaard P, Lund Hetland M, Steen Krogh N, Kollerup G, Jensen J, Chrysidis S, Jensen Hansen IM, Holland-Fischer M, Højland Hansen T, Nilsson C, Espesen J, Nordin H, Rasmussen Loft AG, Pelck R, Lorenzen T, Flejsborg Oeftiger S, Unger B, Jaeger F, Mosborg Petersen P, Rasmussen C, Dreyer L. Impact of tobacco smoking on response to tumour necrosis factor-alpha inhibitor treatment in patients with ankylosing spondylitis: results from the Danish nationwide DANBIO registry. Rheumatology (Oxford). 2016;55:659–68. - PubMed
    1. Zhao S, Thong D, Duffield SJ, Hughes D, Goodson NJ. Alcohol and disease activity in axial spondyloarthritis: a cross-sectional study. Rheumatol Int. 2018;38:375–81. - PMC - PubMed
    1. Durcan L, Wilson F, Conway R, Cunnane G, O’Shea FD. Increased body mass index in ankylosing spondylitis is associated with greater burden of symptoms and poor perceptions of the benefits of exercise. J Rheumatol. 2012;39:2310–4. - PubMed

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