Choosing Biologic Therapies
Hello. I am Jonathan Kay, Professor of Medicine and Director of Clinical Research in the Division of Rheumatology at the University of Massachusetts Medical School and UMass Memorial Medical Center, both in Worcester, Massachusetts.
Today we have many very effective biologic therapies for the treatment of rheumatoid arthritis. We have 5 tumor-necrosis factor (TNF) antagonists, an inhibitor of T-cell costimulation, a drug that interferes with IL-6 binding to its receptor, and a drug that depletes B cells. How do clinicians choose among these various therapies?
This brings up the issue of comparative effectiveness trials. Recently, Axel Finckh and colleagues published data from the Swiss Biologics Registry looking at 100 patients who were previously inadequately responsive to a TNF antagonist and were switched by their physicians in a nonblinded, nonrandomized manner to either a second TNF antagonist or to rituximab. At 6 months, patients who were switched to rituximab had more improvement in rheumatoid arthritis disease activity, fewer tender joints, and lower erythrocyte sedimentation rates, but no improvement in swollen joints compared with patients who were switched to a second TNF antagonist. This study had the limitation of being nonrandomized and open-label.
The ATTEST trial compared adalimumab and infliximab, each with placebo, in the same trial but not directly with one another. This showed that each biologic agent was better than placebo. In an indirect comparison in the same trial, neither drug was significantly better than the other.