Prescribing Antitumor Necrosis Factor Drugs to Patients With Heart Failure

The review article by Amabile and Spencer¹ on medications that should be avoided in patients with congestive heart failure (CHF) was exceptionally well written and informative. However, the authors did not include the anti–tumor necrosis factor (anti-TNF) drugs etanercept and infliximab among the anti-inflammatory medications that should be avoided in patients with CHF. Although these drugs were initially examined as a possible treatment for CHF, studies have shown that they may worsen the clinical condition of patients with heart failure. In the Anti-TNF Therapy Against Congestive Heart Failure (ATTACH) trial, the combined risk of death from any cause or hospitalization for heart failure was significantly increased among the group of patients randomized to 10 mg/kg of infliximab.² The US Food and Drug Administration’s MedWatch program receives mandatory postmarketing reports of adverse events from manufacturers and voluntary reports from health professionals, consumers, and others. Kwon et al³ described 47 patients from the MedWatch program database who developed new or worsening CHF while taking anti-TNF agents. Although these were only case reports, in 9 of 10 younger patients in whom heart failure developed after receiving TNF antagonists, resolution or improvement was noted after the discontinuation of the TNF antagonist and the addition of heart failure therapy, suggesting a link between the anti-TNF drug and CHF. Warnings about the use of anti-TNF drugs in patients with CHF are prominently featured in prescription information about the drugs.⁴ Given the findings in the ATTACH trial, it is recommended that doses of infliximab greater than 5 mg/kg should not be given at all to patients with CHF, and drug labeling for both infliximab and etanercept indicates that these drugs should be used with caution in patients with CHF.⁴