Effects of TNF-α Inhibitors on Subclinical Atherosclerosis and Endothelial Function in Patients with Psoriatic Arthritis: A Systematic Review

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Published Nov 9, 2025
https://doi.org/10.62438/tunismed.v103i9.6331
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Vol. 103 No. 9 (2025): Tunis Med sept 2025

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Yasmine Makhlouf
Department of Rheumatology, Mongi Slim University Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,1007, Tunisia
Hiba Boussaa
Department of Rheumatology, Mongi Slim University Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,1007, Tunisia
Hiba Bettaieb
Internal Medicine Department, Internal Security Forces (ISF) Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar, 1007, Tunisia
Alia Fazaa
Department of Rheumatology, Mongi Slim University Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,1007, Tunisia
Dergaa Ismai
High Institute of Sport and Physical Education of Ksar Saïd, University of Manouba, Manouba 2010, Research Laboratory Education, Motricité, Sport et Santé (EM2S) LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax 3000, Tunisia
Manel Boudokhane
Internal Medicine Department, Internal Security Forces (ISF) Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar, 1007, Tunisia
Syrine Bellakha
Internal Medicine Department, Internal Security Forces (ISF) Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar, 1007, Tunisia
Mohamed Hedi Dougui
Internal Medicine Department, Internal Security Forces (ISF) Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar, 1007, Tunisia
Kawther Ben Abdelghan
Department of Rheumatology, Mongi Slim University Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,1007, Tunisia
Saoussen Miladi
Department of Rheumatology, Mongi Slim University Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,1007, Tunisia
Ahmed Laatar
Department of Rheumatology, Mongi Slim University Hospital, Tunis, Faculty of Medicine of Tunis, University of Tunis El Manar,1007, Tunisia

Abstract

Background: Patients with psoriatic arthritis (PsA) are at increased risk of cardiovascular disease (CVD), largely driven by systemic inflammation and accelerated atherosclerosis. Tumor necrosis factor-alpha (TNF-alpha) inhibitors have transformed PsA treatment and may exert vascular protective effects. This systematic review aimed to evaluate the impact of TNF-alpha inhibitors on atherosclerosis and endothelial dysfunction in PsA patients.


Methods: This systematic review followed the preferred reporting items for systematic reviews guidelines. A systematic search of PubMed, Scopus, Cochrane Library and Embase databases was conducted, identifying original articles up to September 3rd, 2024.  Outcomes included carotid intima-media thickness (CIMT), endothelial function, carotid plaques, and biomarkers of inflammation, lipid metabolism, and coagulation. This systematic review was registered in prospero (CRD42023451234).


Results: Five studies met the inclusion criteria and were published between 2011 and 2020. TNF-alpha inhibitors were associated with a reduction in CIMT in one study (0.7±0.18 vs 0.8±0.26; p=0.002 for the CCA and 0.94±0.31 vs 1.24±0.52; p<0.001 for the bulb), particularly with longer treatment duration (B:-0.317, p<0.001), while two studies reported progression of CIMT over time. Carotid plaque prevalence was significantly lower in TNF-alpha–treated patients compared to those on csDMARDs (15.8% vs 40.4%; p<0.0001). No consistent improvement in endothelial function, assessed by flow-mediated dilation or reactive hyperemia index was observed. TNF-alpha inhibitors consistently reduced inflammatory markers (CRP, ESR) and some lipid parameters (LDL-C, triglycerides). One study showed significant improvement in fibrinolytic and hemostatic markers (p<0.001), especially among patients achieving minimal disease activity (p<0.005).


Conclusion: TNF-alpha inhibitors may offer vascular benefits in PsA by attenuating subclinical atherosclerosis and systemic inflammation. However, their effects on endothelial function remain unclear. Further large-scale, controlled, and long-term studies are warranted to confirm their cardioprotective role and define their impact on clinical cardiovascular outcomes in PsA patients.

Keywords:

Psoriatic arthritis, atherosclerosis, endothelial dysfunction, inflammation, TNF-alpha inhibitors

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