4 Questions About Smoking and Acute Anterior Uveitis Incidence in AxSpA

Acute anterior uveitis (AAU) is the most common extra-axial manifestation of axial spondyloarthritis (axSpA). Research on axSpA has shown a lower likelihood of AAU in current smokers than former smokers or those who have never smoked. However, this is in contrast to a higher risk of AAU among smokers in the general population.

To study this, Sizheng Steven Zhao, MBChB(Hons), MRCP, from the University of Liverpool, and colleagues examined the impact of smoking status on AAU incidence in 2420 patients with axSpA. Results indicated that compared with people who never smoked, both current and former smokers had a higher incidence of AAU, although the association was not statistically significant. The findings showed general trends that smoking was associated with increased incidence of AAU episodes, which suggested that the “protective” effect of smoking seen in other cross-sectional studies is likely not causal.¹

Rheumatology Consultant caught up with Dr Zhao about the research.

Rheumatology Consultant: What prompted you to conduct the study?

Sizheng Steven Zhao: Tobacco smoking is one of the greatest threats to health in our time. There is evidence that smoking may cause greater functional decline in axSpA. Smoking also increases the risk of uveitis in the general population. We were surprised to see 3 prior cross-sectional studies showing a lower prevalence of uveitis among axSpA patients who smoke. This was contrary to what we know about smoking, so we decided to look into it further and examined data over a long period of time.

RHEUM CON: What was the most surprising finding from your study?

SZ: When we looked at the data over time, we saw that patients with axSpA who were current smokers had a higher risk of AAU attacks than those who did not smoke. People who managed to quit smoking had a slightly lower risk of AAU attacks than those who continued to smoke, but still had a higher risk than people who never smoked.

RHEUM CON: Should smoking cessation be universally recommended to all smokers with axSpA to prevent incidence of AAU?

SZ: Smoking causes faster disease progression of axSpA. It also causes heart disease, which axSpA patients are already at higher risk for. So, providers should routinely recommend smoking cessation; this is supported by the European League Against Rheumatism (EULAR) guidelines for axSpA management.² However, we do not know whether introducing practical methods—nicotine replacement, e-cigarettes, and others—to help patients with axSpA quit smoking will be cost-effective.

RHEUM CON: Can smoking interfere with management of AAU and/or axSpA?

SZ: The current evidence suggests that smoking status does not impair a patient’s response to axSpA treatment with tumor necrosis factor inhibitors. So those patients who try but struggle to quit should not be disadvantaged in receiving treatment. But as we discussed, smoking is detrimental for many aspects of health. Rheumatologists should be aware that smokers may have more attacks of AAU and highlight this to patients as an important reason to quit. Sight is incredibly precious to people. Patients should also be educated about having a higher risk of developing psoriasis if they smoke.

References:

1. Zhao SS, Macfarlane GJ, Jones GT, et al. Smoking does not protect patients with axial spondyloarthritis from attacks of uveitis. Ann Rheum Dis. 2019;78(9):1287-1288. doi:10.1136/annrheumdis-2019-215348.
2. van der Heijde D, Ramiro S, Landewé R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-991. doi:10.1136/annrheumdis-2016-210770.

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