Korean J Intern Med.  2017 May;32(3):536-547. 10.3904/kjim.2015.135.

Comparative efficacy of biological agents in methotrexate-refractory rheumatoid arthritis patients: a Bayesian mixed treatment comparison

• Choi M
• Hyun MK
• Choi S
• Tchoe HJ
• Lee SY
• Son KM
• Kim MJ
• Jung YO
• Kim HA

• KMID: 2379485
• DOI: http://doi.org/10.3904/kjim.2015.135

Abstract

BACKGROUND/AIMS
Biological agents (biologics) targeting proinflammatory signaling have emerged as an important treatment option in rheumatoid arthritis (RA). Despite the clinical effectiveness of biologics for patients with RA who do not respond to "˜traditional' disease-modifying anti-rheumatic drugs (DMARDs), there are concerns regarding their cost and long-term safety. In this study, we aimed to compare the efficacy of various biologics and traditional DMARDs in RA patients refractory to methotrexate (MTX).
METHODS
Four DMARDs (hydroxychloroquine, sulfasalazine, MTX, leflunomide) and five anti-tumor necrosis factor drugs (adalimumab, etanercept, golimumab, infliximab, and certolizumab) were selected. A systematic search of published studies was performed from inception through July 2013. Randomized trials of adults with MTX-refractory RA comparing two or more of the selected medications were included. Among 7,938 titles identified, in total, 16 head-to-head trials were selected. Two reviewers independently abstracted the study data and assessed methodological quality using the Cochrane Risk of Bias. Comparative efficacy was analyzed using a Bayesian mixed treatment comparison (MTC).
RESULTS
In total, 9, 4, and 11 studies were included for the outcome measures of the Health Assessment Questionnaire (HAQ), Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) < 2.6 (remission), and American College of Rheumatology (ACR) 70 response, respectively. The treatments with the highest efficacy for each outcome measure were certolizumab combined with MTX, golimumab combined with MTX, and certolizumab combined with MTX, respectively.
CONCLUSIONS
Based on MTC analysis, using data from published randomized controlled trials, certolizumab and golimumab combined with MTX showed the highest efficacy in the three outcome measures (HAQ, DAS28-ESR < 2.6, and ACR 70 response) in MTX-refractory RA patients.

Keyword

Arthritis, rheumatoid; Antirheumatic agents; Biological products; Mixed treatment comparison

MeSH Terms

Adult
Antirheumatic Agents
Arthritis, Rheumatoid*
Bias (Epidemiology)
Biological Factors*
Biological Products
Etanercept
Humans
Infliximab
Methotrexate
Necrosis
Outcome Assessment (Health Care)
Rheumatology
Sulfasalazine
Treatment Outcome
Antirheumatic Agents
Biological Factors
Biological Products
Etanercept
Infliximab
Methotrexate
Sulfasalazine