Would you consider using a TNFi in a patient with a family history of demyelinating disease, in the absence of a personal history?
No contraindication based on family history of MS that I am aware of. One could consider MRI head to rule out radiologically isolated syndrome, as a biomarker of risk.
The FDA database has identified several cases of new onset multiple sclerosis following TNF-inhibitor therapy [1]. There is still uncertainty whether TNF-inhibitors actually cause de novo cases versus triggering an exacerbation in those with underlying demyelinating disease.
Given that we have many options to control inflammatory arthritis, I personally avoid this drug class in patients with a family history of MS/demyelinating disease or optic neuritis. If the patient has no other option, then they are counseled extensively on this topic and know to report any new neurologic symptoms immediately. The risk is still very low overall but until we know more, best to be cautious.