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.

Aberdeen Centre for Arthritis and Musculoskeletal Health University of Aberdeen Aberdeen UK

Center for Rheumatic Diseases University of Medicine and Pharmacy Romanian Registry of Rheumatic Diseases Bucharest Romania

Center for Treatment of Rheumatic and Musculoskeletal Diseases Diakonhjemmet Hospital Oslo Norway

Centre for Rheumatology Research Landspitali University Hospital Reykjavik Iceland

Centre for Rheumatology Tampere University Hospital Tampere Finland

Copenhagen Center for Arthritis Research Center for Rheumatology and Spine Diseases Centre of Head and Orthopedics Rigshospitalet Glostrup Denmark

Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark

Department of Rheumatology 1st Faculty of Medicine Charles University Prague Czech Republic

Department of Rheumatology Geneva University Hospital Geneva Switzerland

Department of Rheumatology Landspitali University Hospital Reykjavik Iceland

Department of Rheumatology Radboud University Medical Centre Nijmegen The Netherlands

Department of Rheumatology University Medical Centre Ljubljana Ljubljana Slovenia

Department of Rheumatology Zurich University Hospital University of Zurich Zurich Switzerland

Faculty of Medicine and Health Technology Tampere University Tampere Finland

Faculty of Medicine University of Iceland Reykjavik Iceland

Faculty of Medicine University of Ljubljana Ljubljana Slovenia

Institute of Rheumatology Prague Czech Republic

Lund University Lund Sweden

Research Unit Sørlandet Hospital Kristiansand Norway

Rheumatology Inflammation Center Helsinki University Hospital and University of Helsinki Helsinki Finland

Rheumatology Research Unit Instituto de Medicina Molecular Faculdade de Medicina de Lisboa Lisbon Portugal

Serviço de Reumatologia Hospital Garcia de Orta Reuma pt Almada Portugal

Skåne University Hospital Lund Sweden

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