Adalimumab, a fully human anti-TNF-alpha monoclonal antibody, treatment does not influence experimental UV response in the skin of rheumatoid arthritis patients

Targeted treatment of psoriasis with adalimumab: a critical appraisal based on a systematic review of the literature

Psoriasis is a chronic inflammatory disease affecting 2% to 3% of the population in Western countries. Psoriasis is associated with limited quality of life, cardiovascular disease, and depression. The approval of injectable biological agents has revolutionized the management of moderate to severe psoriasis. Adalimumab is a human monoclonal antibody against tumor necrosis factor (TNF) alpha approved for moderate-to-severe plaque-type psoriasis and psoriatic arthritis (PsA). This systematic review summarizes the evidence concerning the efficacy, clinical effectiveness, safety, and cost-effectiveness of adalimumab in the treatment of psoriasis. Five randomized controlled trials demonstrated the efficacy of adalimumab in moderate-to-severe plaque-type psoriasis and PsA with PASI-75 response rates of 53% to 80% and ACR-20 response rates of 39% to 58% after 12 to 16 weeks of treatment. In clinical practice patients who have not responded to one TNF antagonist may respond to another TNF antagonist. Adalimumab has similar or better cost-effectiveness than other biologics, but is less efficient than methotrexate and cyclosporine. Adalimumab is generally well tolerated. Patients should be evaluated for active/latent tuberculosis, serious infections, and other contraindications prior to initiation of adalimumab therapy. Future studies should investigate the comparative efficacy of adalimumab and other biologic and prebiologic agents. Recently established registries will yield additional data on the effectiveness and long-term safety of adalimumab.

Systemische Psoriasistherapie – der nächste Schritt

Adalimumab is the first fully human monoclonal antibody against TNFalpha and has been approved for treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. Its efficacy for both joint and skin involvement has been confirmed in clinical trials. The recommended dose is 40 mg administered every other week subcutaneously. It may be combined with methotrexate and all topical psoriasis treatment modalities. User-friendly administration devices make self-injection possible. Patients should be evaluated for active/latent tuberculosis and serious infections prior to initiation of therapy. Adalimumab rapidly reduces joint symptoms within a few days. Adalimumab is used for the management of adult psoriatic arthritis patients who have had an inadequate response to disease-modifying antirheumatic drugs. Adalimumab is yet another biological for the treatment of psoriasis. Since the TNFalpha antagonists can be switched if one is ineffective, this agent broadens the therapeutic spectrum.

Tumor necrosis factor receptor 1/c-Jun-NH2-kinase signaling promotes human neoplasia

The tumor necrosis factor alpha receptor (TNFR1) activates downstream effectors that include the mitogen-activated protein kinase kinase 7 (MKK7)/c-Jun-NH(2)-kinase (JNK)/activator protein 1 (AP1) cascade. Here, we report that JNK is activated in a majority of spontaneous human squamous cell carcinomas (SCC). JNK pathway induction bypassed cell cycle restraints induced by oncogenic Ras and cooperated with Ras to convert normal human epidermis into tumors indistinguishable from SCC, confirming its oncogenic potency in human tissue. Inhibiting MKK7, JNK, and AP1 as well as TNFR1 itself using genetic, pharmacologic, or antibody-mediated approaches abolished invasive human epidermal neoplasia in a tumor cell autonomous fashion. The TNFR1/MKK7/JNK/AP1 cascade thus promotes human neoplasia and represents a potential therapeutic target for human epithelial cancers.

Adalimumab for treating rheumatoid arthritis

BACKGROUND

Adalimumab is a fully human anti-TNFalpha monoclonal antibody. Published studies indicate that its use in patients with RA can be effective and safe.

OBJECTIVES

The aim of this review was to assess the efficacy and safety of adalimumab in the treatment of RA.

SEARCH STRATEGY

Electronic databases were searched up to August, 2004: MEDLINE, CINAHL, EBM Reviews (CDSR, ACP Journal Club, DARE and CENTRAL) and Health STAR. Conference proceedings were hand searched and pharmaceutical companies were contacted to obtain additional unpublished data from published trials. Adalimumab was searched as a text word as it is not currently indexed. The search was not limited by language, year of publication or type of publication.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing adalimumab alone or in combination with DMARDs to placebo or other DMARDs.

DATA COLLECTION AND ANALYSIS

Two reviewers independently collected the data in a standardized form and assessed the methodological quality of the trial using validated criteria. Outcome measures included ACR and EULAR responses, DAS 28 and components of ACR response and radiographic data. Safety data were also included. Continuous data were reported as weighted mean difference (WMD) with 95% confidence interval (95%CI), absolute benefit (AB) and relative difference (RD). Dichotomous outcomes were reported as relative risk (RR) with 95% CI, absolute risk difference (ARD) or risk difference (RDiff) with 95%CI and number needed to treat (NNT) or to harm (NNH). When significant heterogeneity was not found, data were pooled.

MAIN RESULTS

Six studies with 2381 patients were included in this review. Two comparisons were done: A. adalimumab subcutaneously (sc) + methotrexate (or DMARDs) versus placebo sc + methotrexate (or DMARDs). B. adalimumab sc in monotherapy versus placebo sc. In the comparison A, with adalimumab 40 mg every other week (e.o.w.), the RR to achieve an ACR 20 response at 24 weeks ranged in the included studies from 1.52 to 4.63, and the NNT ranged from 1.9 to 5.4. The RR (95%CI) to achieve an ACR 50 response was 4.63 (3.04-7.05), and the NNT was 3.0 (95%CI 2.0-6.0). The RR (95%CI) to achieve an ACR 70 response was 5.14 (3.14-8.41) and the number needed to treat was 7.0 (95%CI 5.0-13.0). At 52 weeks, the RRs (95%CI) to achieve an ACR 20, 50, and 70 response were 2.46 (1.87-3.22), 4.37 (2.77-6.91), and 5.15 (2.60-10.22), with NNTs of 2.9, 3.1, and 5.3, respectively. At 52 weeks, adalimumab 40 mg e.o.w. and 20 mg every week (e.w.) significantly slowed the radiological progression including Sharp modified index, erosion score, and joint space score (only with 40 mg e.o.w.). In the comparison B, with adalimumab 40 mg e.o w. , the RRs to achieve an ACR 20, 50, and 70 response at 24/26 weeks were 1.91 (1.17-3.10), 2.84 (1.58-5.12), and 7.33 (2.25-33.90) with NNTs of 5.0 (95%CI 3.0-9.0), 7.0 (4.0-20.0), and 9.0 (3.0-38.0), respectively. In most of the analysed studies and comparisons, there were not significant differences in safety outcomes between adalimumab and control groups. The development of positive antinuclear antibodies was significantly more frequent in adalimumab patients than in placebo patients. Serious infections were significantly more frequent in adalimumab patients in only one study (Keystone 2004) with a RR (95%CI) of 7.64(1.02-57.18) and a NNH of 30.2.

AUTHORS' CONCLUSIONS

On the basis of the studies reviewed here, adalimumab in combination with methotrexate is efficacious and safe in the treatment of the rheumatoid arthritis. Adalimumab 40 mg sc e.o.w. and 20 mg e.w. slows the radiographic progression at 52 weeks. Adalimumab in combination with DMARDs other than methotrexate is also efficacious and safe, even though data from one only study are available and the number of patients in each group is low. Adalimumab in monotherapy is efficacious and safe in the treatment of the rheumatoid arthritis but the effect size is lower than with combined therapy.