Tumor necrosis factor inhibitors are associated with reduced complement activation in spondylarthropathies: An observational study

PLoS One. 2019 Jul 23;14(7):e0220079. doi: 10.1371/journal.pone.0220079. eCollection 2019.


Background: The complement system is involved in pathogenesis of cardiovascular disease, and might play a role in accelerated atherogenesis in spondylarthropathies (SpA). Hence, we examined complement activation in SpA, and its relationship to antirheumatic treatment, inflammatory and cardiovascular markers.

Methods: From PSARA, a prospective observational study, we examined 51 SpA patients (31 psoriatic arthritis (PsA), and 20 ankylosing spondylitis (AS)), starting tumor necrosis factor (TNF) inhibitor alone (n = 25), combined with methotrexate (MTX) (n = 10), or MTX monotherapy (n = 16). Complement activation was determined by the soluble terminal complement complex (sC5b-9), inflammation by erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and endothelial function by finger plethysmography (Endopat) at baseline, after 6 weeks and 6 months of treatment.

Results: SpA patients had sC5b-9 levels at (PsA) or above (AS) the upper limit of the estimated reference range. Median sC5b-9 levels decreased significantly from baseline to 6 weeks, with no significant difference between the AS and PsA group. Notably, a significant reduction in sC5b-9 was observed after administration of TNF inhibitor ± MTX, whereas no significant changes were observed in patients treated with MTX alone. Between 6 weeks and 6 months, sC5b-9 remained stable across all subgroups. Reduction in sC5b-9 was independently related to decreased ESR and CRP, and to increased high density cholesterol and total cholesterol. Reduction in sC5b-9 from baseline to 6 weeks was associated with improved EF in age and gender adjusted analyses.

Conclusion: TNF-inhibition, but not MTX monotherapy, led to rapid and sustained reduction of complement activation in SpA. Thus, the observed decrease in cardiovascular morbidity in patients treated with TNF-inhibitors might be partly due to its beneficial effect on complement.

Trial registration: Clinical Trials (NCT00902005), retrospectively registered on the 14th of May 2009.

Publication types

  • Controlled Clinical Trial
  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Complement Activation / drug effects*
  • Complement Membrane Attack Complex / immunology
  • Female
  • Humans
  • Male
  • Methotrexate / administration & dosage
  • Methotrexate / pharmacology
  • Methotrexate / therapeutic use
  • Middle Aged
  • Spondylarthropathies / blood
  • Spondylarthropathies / drug therapy
  • Spondylarthropathies / immunology*
  • Tumor Necrosis Factor Inhibitors / administration & dosage
  • Tumor Necrosis Factor Inhibitors / pharmacology*
  • Tumor Necrosis Factor Inhibitors / therapeutic use


  • Complement Membrane Attack Complex
  • SC5b-9 protein complex
  • Tumor Necrosis Factor Inhibitors
  • Methotrexate

Associated data

  • ClinicalTrials.gov/NCT00902005

Grant support

The first author’s PhD scholarship is funded by The Norwegian Women's Public Health Association, Grant 14902, URL: https://www.sanitetskvinnene.no/. Financial support to the complement analyses was kindly provided by The Norwegian Council on Cardiovascular Disease, The Odd Fellow Foundation and The Simon Fougner Hartmann Family Fund, URL: https://nasjonalforeningen.no/, https://www.oddfellow.no/, and no webpage, respectively. The establishment of PSARA biobank was sponsored by Abbott Laboratories Norway - now Abbvie, URL: https://www.abbvie.no/. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.