Is the risk of infection higher during treatment with secukinumab than with TNF inhibitors? An observational study from the Nordic countries

Rheumatology (Oxford). 2023 Feb 1;62(2):647-658. doi: 10.1093/rheumatology/keac358.


Objectives: The positioning of secukinumab in the treatment of axial SpA (axSpA) and PsA is debated, partly due to a limited understanding of the comparative safety of the available treatments. We aimed to assess the risk of the key safety outcome infections during treatment with secukinumab and TNF inhibitors (TNFi).

Methods: Patients with SpA and PsA starting secukinumab or TNFi year 2015 through 2018 were identified in four Nordic rheumatology registers. The first hospitalized infection during the first year of treatment was identified through linkage to national registers. Incidence rates (IRs) with 95% CIs per 100 patient-years were calculated. Adjusted hazard ratios were estimated through Cox regression, with secukinumab as the reference. Several sensitivity analyses were performed to investigate confounding by indication.

Results: Among 7708 patients with SpA and 5760 patients with PsA, we identified 16 229 treatment courses of TNFi (53% bionaïve) and 1948 with secukinumab (11% bionaïve). For secukinumab, the first-year risk of hospitalized infection was 3.5% (IR 5.0; 3.9-6.3), compared with 1.7% (IR 2.3; 1.7-3.0) during 3201 courses with adalimumab, with the IRs for other TNFi lying in between these values. The adjusted HR for adalimumab, compared with secukinumab, was 0.58 (0.39-0.85). In sensitivity analyses, the difference from secukinumab was somewhat attenuated and in some analyses no longer statistically significant.

Conclusion: When used according to clinical practice in the Nordic countries, the observed first-year absolute risk of hospitalized infection was doubled for secukinumab compared with adalimumab. This excess risk seemed largely explained by confounding by indication.

Keywords: DMARDs; biologic therapies; epidemiology; immunosuppressants; spondylarthropathies.

Publication types

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

MeSH terms

  • Adalimumab / adverse effects
  • Antirheumatic Agents* / adverse effects
  • Arthritis, Psoriatic* / drug therapy
  • Humans
  • Scandinavian and Nordic Countries / epidemiology
  • Treatment Outcome
  • Tumor Necrosis Factor Inhibitors / adverse effects


  • Adalimumab
  • secukinumab
  • Tumor Necrosis Factor Inhibitors
  • Antirheumatic Agents