The reason why anti-TNF-alpha agents are underutilized in patients with diabetes is likely due to the increased fragility of these patients, both because of the immune system deficiency that makes them more susceptible to infections (to which anti-TNF-alpha agents could further expose them), and due to the older age of this population, which is associated with the presence of multiple comorbidities, including those in which anti-TNF-alpha agents are contraindicated (e.g., heart failure). Here, TNF is linked to heart failure.