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Peng K, Chan SCW, Wang Y, Cheng FWT, Yeung WWY, Jiao Y, Chan EWY, Wong ICK, Lau CS, Li X. Cost-Effectiveness of Biosimilars vs Leflunomide in Patients With Rheumatoid Arthritis. JAMA Netw Open 2024; 7:e2418800. [PMID: 38922614 PMCID: PMC11208978 DOI: 10.1001/jamanetworkopen.2024.18800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/25/2024] [Indexed: 06/27/2024] Open
Abstract
Importance Among patients with rheumatoid arthritis (RA) who had an inadequate response to methotrexate, a treatment sequence initiated with biosimilar disease-modifying antirheumatic drugs (DMARDs) provides better clinical efficacy compared with conventional synthetic DMARDs recommended by current treatment guidelines; but its cost-effectiveness evidence remains unclear. Objective To evaluate the cost-effectiveness of the treatment sequence initiated with biosimilar DMARDs after failure with methotrexate vs leflunomide and inform formulary listing decisions. Design, Setting, and Participants This economic evaluation's cost-effectiveness analysis was performed at a Hong Kong public institution using the Markov disease transition model to simulate the lifetime disease progression and cost for patients with RA, using monetary value in 2022. Scenario and sensitivity analyses were performed to test the internal validity of the modeling conclusion. Participants included patients diagnosed with RA from 2000 to 2021 who were retrieved retrospectively from local electronic medical records to generate model input parameters. Statistical analysis was performed from January 2023 to March 2024. Interventions The model assesses 3 competing treatment sequences initiated with biosimilar infliximab (CT-P13), biosimilar adalimumab (ABP-501), and leflunomide; all used in combination with methotrexate. Main Outcomes and Measures Lifetime health care cost and quality-adjusted life-years (QALYs) of the simulated cohort. Results In total, 25 099 patients with RA were identified (mean [SD] age, 56 [17] years; 19 469 [72.7%] women). In the base-case analysis, the lifetime health care cost and QALYs for the treatment sequence initiated with leflunomide were US $154 632 and 14.82 QALYs, respectively; for biosimilar infliximab, they were US $152 326 and 15.35 QALYs, respectively; and for biosimilar adalimumab, they were US $145 419 and 15.55 QALYs, respectively. Both biosimilar sequences presented lower costs and greater QALYs than the leflunomide sequence. In the deterministic sensitivity analysis, the incremental cost-effectiveness ratio (US$/QALY) comparing biosimilar infliximab sequence vs leflunomide sequence and biosimilar adalimumab sequence vs leflunomide sequence ranged from -15 797 to -8615 and -9088 to 10 238, respectively, all below the predefined willingness-to-pay threshold (US $48 555/QALY gain). In the probabilistic sensitivity analysis, the probability of treatment sequence initiated with leflunomide, biosimilar infliximab, and biosmilar adalimumab being cost-effective out of 10 000 iterations was 0%, 9%, and 91%, respectively. Conclusions and Relevance In this economic evaluation study, the treatment sequences initiated with biosimilar DMARDs were cost-effective compared with the treatment sequence initiated with leflunomide in managing patients with RA who experienced failure with the initial methotrexate treatment. These results suggest the need to update clinical treatment guidelines for initiating biosimilars immediately after the failure of methotrexate for patients with RA.
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Affiliation(s)
- Kuan Peng
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Shirley C. W. Chan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yang Wang
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Franco W. T. Cheng
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Winnie W. Y. Yeung
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yuanshi Jiao
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Esther W. Y. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
| | - Ian C. K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
- School of Pharmacy, Aston University, Birmingham, England
| | - Chak-Sing Lau
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Xue Li
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
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Ejaz S, Gurugubelli S, Prathi SK, Palou Martinez Y, Arrey Agbor DB, Panday P, Yu AK. The Role of Etanercept in Controlling Clinical and Radiological Progression in Rheumatoid Arthritis: A Systematic Review. Cureus 2024; 16:e58112. [PMID: 38738082 PMCID: PMC11088797 DOI: 10.7759/cureus.58112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Etanercept (ETN) is a disease-modifying anti-rheumatic drug (DMARD) used in the treatment of rheumatoid arthritis (RA) that works as a tumor necrosis factor inhibitor (TNF inhibitor) by blocking the effects of naturally occurring TNF. This review will evaluate the effect of ETN as a monotherapy or combination therapy with methotrexate (MTX) in the treatment of RA. This systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. A systematic search was done on PubMed and Google Scholar from 1999 to 2023. Predefined eligibility criteria were set for selected studies, which include: free full-text articles published; randomized control trials (RCTs); systematic reviews and meta-analyses; and observational studies in a patient with RA treated with ETN as initial therapy or as an add-on to conventional disease-modified therapy. Hence, the data had been extracted, and a quality assessment of each study was done by two individual authors. When comparing patients who received 15-25 mg of MTX with those who also received 25 mg of ETN in combination, 71% achieved American College of Rheumatology 20 (ACR20) by 24 weeks, compared to 27% in the MTX and placebo groups (p<0.001), and 39% achieved American College of Rheumatology 50 (ACR50), compared to 3% in the placebo + MTX group (p<0.001). Low disease activity (DAS 28) was more common in patients who had both MTX and ETN (64.5% with DAS <2.4 and 56.3% with DAS 28 <3.2) compared to patients who received only one medication (44.4% with DAS <2.4 and 33.2% with DAS 28 <3.2 for ETN and 38.6% with DAS <2.4 and 28.5% with DAS 28 <3.2 for MTX, with P<0.01). ETN demonstrated smaller changes from baseline in the modified Sharp score (TSS) and erosion scores (ES) at 12 months and two years, as well as a decreased change in the ES score at one year (with a trend of P value = 0.06 for the TSS score), in comparison to those receiving DMARD. Reactions at the injection site (42% vs. 7%, P<0.001) were the only events that occurred significantly more frequently in the ETN plus-MTX group. Combining ETN and MTX appears to help control RA symptoms by decreasing the American College of Rheumatology (ACR) response and DAS score, as well as halting the disease's progression on X-rays. The most common adverse effects were reactions to ETN administered alone at the injection site, likely because of patient awareness of the treatment received. There was also concern about tuberculosis and malignancy, but no recent data is available. Therefore, a larger clinical trial with longer follow-up is required to ascertain long-term safety and benefits.
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Affiliation(s)
- Samrah Ejaz
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Simhachalam Gurugubelli
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Memorial Healthcare, Gulfport, USA
| | - Suviksh K Prathi
- General Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- General Medicine, St. George's University School of Medicine, St. Georges, GRD
| | - Yaneisi Palou Martinez
- Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Divine Besong Arrey Agbor
- Clinical Research and Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Richmond University Medical Center, New York City, USA
| | - Priyanka Panday
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ann Kashmer Yu
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Meng Y, Zheng X, Zhang Z, Geng H, Li X. Circulating PCSK9 relates to aggravated disease activity, Th17/Treg imbalance, and predicts treatment outcome of conventional synthetic DMARDs in rheumatoid arthritis patients. Ir J Med Sci 2023; 192:3187-3194. [PMID: 36826711 DOI: 10.1007/s11845-023-03323-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/17/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) regulates inflammatory response and CD4+ T cell differentiation in autoimmune diseases, while its clinical role in rheumatoid arthritis (RA) lacks sufficient evidence. Subsequently, this study intended to explore the vertical change of PCSK9, and its linkage with T helper (Th) cells, regulatory T (Treg) cells, clinical features, and treatment outcomes in RA patients. METHODS This multi-center, prospective, cohort study determined serum PCSK9 in 89 RA patients who received conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and 50 healthy controls (HCs) after recruitment by enzyme-linked immunosorbent assay. For RA patients, serum PCSK9 was also determined at 6th week, 12th week, and 24th week; meanwhile, Th1, Th2, Th17, and Treg cells at baseline were determined through flow cytometry. RESULTS PCSK9 was increased in RA patients compared to HCs (median: 209.2 versus 122.0 ng/mL, P < 0.001). In RA patients, PCSK9 positively correlated with Th17 cells (P = 0.023) and Th17/Treg ratio (P = 0.018), but did not link with Th1 cells, Th2 cells, Th1/Th2 ratio, or Treg cells. Meanwhile, PCSK9 was not associated with any demographics and medication histories, while it positively correlated with C-reactive protein (P = 0.010), disease activity score in 28 joints (P = 0.009), physician's global assessment (P = 0.015), and clinical disease activity index (P = 0.040). Importantly, PCSK9 gradually reduced from baseline to 24th week; its decrement related to higher possibility of treatment response (P = 0.002), low disease activity (P = 0.001), and remission of csDMARDs (P = 0.012). CONCLUSION Circulating PCSK9 shows the potency as a biomarker for disease management and treatment outcome prediction of csDMARDs in RA.
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Affiliation(s)
- Yanan Meng
- Department of Clinical Laboratory, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Xiaomeng Zheng
- Department of Clinical Laboratory, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Zheng Zhang
- Department of Rheumatology and Immunology, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Huijuan Geng
- Department of Clinical Laboratory, Baoding People's Hospital, Baoding, Hebei, China
| | - Xiaodong Li
- Department of Nuclear Medicine, Affiliated Hospital of Hebei University, No. 212, Yuhua Dong Road, Baoding, Hebei, 071000, China.
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Narváez J, Otón T, Calvo-Alén J, Escudero-Contreras A, Muñoz-Fernández S, Rodríguez-Heredia JM, Romero-Yuste S, Vela-Casasempere P, Luján S, Baquero JL, Carmona L. Influence of prognosis factors on the prescription of targeted treatments in rheumatoid arthritis: A Delphi survey. Joint Bone Spine 2021; 88:105172. [PMID: 33689842 DOI: 10.1016/j.jbspin.2021.105172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To explore current evidence on the management of poor prognostic factors in rheumatoid arthritis (RA) and to investigate whether this evidence is taken into account by clinicians when deciding on treatment in daily clinical practice. METHODS We performed a systematic literature review (SLR) to analyse the effects of currently available biologic disease-modifying antirheumatic drugs (bDMARDs) and Janus kinase inhibitors (JAKi) on the classically accepted poor prognostic factors of RA. All randomized controlled trials reporting subgroup analyses about effects on prognostic factors were identified and synthesized. In a second phase, a two-round Delphi survey was carried out to contrast the SLR results with the grade of agreement of a large group of rheumatologists about the effectiveness of each drug class on each prognostic factor. RESULTS According to the Delphi results, the only prognostic factor that significantly influenced the selection of treatment was the presence of interstitial lung disease (ILD), being the preferred treatment in this scenario abatacept or rituximab. The rest of the poor prognostic factors (including high disease activity at baseline, disability as measured by the Health Assessment Questionnaire index, seropositivity, elevated acute-phase reactants, and evidence of erosions based on plain radiography or ultrasonography) did not seem to significantly influence rheumatologists when choosing a treatment. The results of the SLR results did not show solid evidence regarding the use of any specific therapy in the management of patients with specific poor factors, except in the case of RA-ILD, although the data in the literature in this regard are not free of bias. CONCLUSIONS The only prognostic factor that seems to significantly influence the selection of treatment is the presence of RA-ILD.
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Affiliation(s)
| | - Teresa Otón
- Instituto de Salud Musculoesquelética (InMusc), Calle Ofelia Nieto, 10, Madrid, Spain
| | | | - Alejandro Escudero-Contreras
- Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | | | | | | | | | - Sara Luján
- Medical Department, Bristol-Myers Squibb, Madrid, Spain
| | | | - Loreto Carmona
- Instituto de Salud Musculoesquelética (InMusc), Calle Ofelia Nieto, 10, Madrid, Spain.
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Archer R, Hock E, Hamilton J, Stevens J, Essat M, Poku E, Clowes M, Pandor A, Stevenson M. Assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews. Health Technol Assess 2019; 22:1-294. [PMID: 30501821 DOI: 10.3310/hta22660] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic, debilitating disease associated with reduced quality of life and substantial costs. It is unclear which tests and assessment tools allow the best assessment of prognosis in people with early RA and whether or not variables predict the response of patients to different drug treatments. OBJECTIVE To systematically review evidence on the use of selected tests and assessment tools in patients with early RA (1) in the evaluation of a prognosis (review 1) and (2) as predictive markers of treatment response (review 2). DATA SOURCES Electronic databases (e.g. MEDLINE, EMBASE, The Cochrane Library, Web of Science Conference Proceedings; searched to September 2016), registers, key websites, hand-searching of reference lists of included studies and key systematic reviews and contact with experts. STUDY SELECTION Review 1 - primary studies on the development, external validation and impact of clinical prediction models for selected outcomes in adult early RA patients. Review 2 - primary studies on the interaction between selected baseline covariates and treatment (conventional and biological disease-modifying antirheumatic drugs) on salient outcomes in adult early RA patients. RESULTS Review 1 - 22 model development studies and one combined model development/external validation study reporting 39 clinical prediction models were included. Five external validation studies evaluating eight clinical prediction models for radiographic joint damage were also included. c-statistics from internal validation ranged from 0.63 to 0.87 for radiographic progression (different definitions, six studies) and 0.78 to 0.82 for the Health Assessment Questionnaire (HAQ). Predictive performance in external validations varied considerably. Three models [(1) Active controlled Study of Patients receiving Infliximab for the treatment of Rheumatoid arthritis of Early onset (ASPIRE) C-reactive protein (ASPIRE CRP), (2) ASPIRE erythrocyte sedimentation rate (ASPIRE ESR) and (3) Behandelings Strategie (BeSt)] were externally validated using the same outcome definition in more than one population. Results of the random-effects meta-analysis suggested substantial uncertainty in the expected predictive performance of models in a new sample of patients. Review 2 - 12 studies were identified. Covariates examined included anti-citrullinated protein/peptide anti-body (ACPA) status, smoking status, erosions, rheumatoid factor status, C-reactive protein level, erythrocyte sedimentation rate, swollen joint count (SJC), body mass index and vascularity of synovium on power Doppler ultrasound (PDUS). Outcomes examined included erosions/radiographic progression, disease activity, physical function and Disease Activity Score-28 remission. There was statistical evidence to suggest that ACPA status, SJC and PDUS status at baseline may be treatment effect modifiers, but not necessarily that they are prognostic of response for all treatments. Most of the results were subject to considerable uncertainty and were not statistically significant. LIMITATIONS The meta-analysis in review 1 was limited by the availability of only a small number of external validation studies. Studies rarely investigated the interaction between predictors and treatment. SUGGESTED RESEARCH PRIORITIES Collaborative research (including the use of individual participant data) is needed to further develop and externally validate the clinical prediction models. The clinical prediction models should be validated with respect to individual treatments. Future assessments of treatment by covariate interactions should follow good statistical practice. CONCLUSIONS Review 1 - uncertainty remains over the optimal prediction model(s) for use in clinical practice. Review 2 - in general, there was insufficient evidence that the effect of treatment depended on baseline characteristics. STUDY REGISTRATION This study is registered as PROSPERO CRD42016042402. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Rachel Archer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Munira Essat
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Ma K, Li L, Liu C, Zhou L, Zhou X. Efficacy and safety of various anti-rheumatic treatments for patients with rheumatoid arthritis: a network meta-analysis. Arch Med Sci 2019; 15:33-54. [PMID: 30697252 PMCID: PMC6348345 DOI: 10.5114/aoms.2018.73714] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/22/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Biologics and traditional disease-modifying anti-rheumatic drugs (DMARDs) are generally used in treating patients with rheumatoid arthritis (RA). Previous studies have presented abundant data and information about the efficacy of such treatments, but the results were incomplete and inconclusive. This network meta-analysis was conducted to compare and assess the efficacy and safety of 15 therapies employing biologics and DMARDs for RA patients. MATERIAL AND METHODS Six outcomes (American College of Rheumatology 20% response rate (ACR20), ACR50, ACR70, remission, adverse events (AEs) and serious adverse events (SAEs)) were used to evaluate the efficacy and safety of different treatments. The node-splitting method was used to assess the inconsistency, and the rank probabilities of the therapies were estimated by surface under the cumulative ranking curve. Besides, Jadad scale was used to evaluate the methodological quality of eligible studies. RESULTS A total of 67 randomized controlled trials with 20,898 patients met the inclusion criteria. Most of the therapies presented better performance than conventional DMARDs (cDMARDs) and placebo in ACR20, ACR50 and ACR70. Conversely, the safety of cDMARDs and placebo seemed to be superior in AEs and SAEs. Also, tocilizumab (TCZ) and TCZ + methotrexate (MTX) showed better remission in pain compared to other treatments. Overall, certolizumab pegol (CZP) + MTX and TCZ + MTX had higher probability than the other treatments in efficacy outcomes. CONCLUSIONS We recommend CZP + MTX as the optimal drug therapy because it has the highest ranking in efficacy outcomes and relatively low risk of adverse events. TCZ + MTX is recommended as an alternative. Abatacept (ABT) and cDMARDs are not recommended due to their low efficacy.
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Affiliation(s)
- Kexun Ma
- The First Clinical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Ling Li
- Department of Rheumatology, Taizhou Hospital of TCM, Taizhou, Jiangsu, China
| | - Chunhui Liu
- The First Clinical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Lingling Zhou
- College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Xueping Zhou
- The First Clinical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
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Calvo Alén J, Pérez T, Romero Yuste S, Ferraz-Amaro I, Alegre Sancho JJ, Pinto Tasende JA, Maceiras Pan F, Quevedo JC, Hernández-Hernández MV, Hidalgo Calleja C, San Martín Álvarez A, Sánchez MIT, Sanmartí R. Efficacy and Safety of Combined Therapy With Synthetic Disease-modifying Antirheumatic Drugs in Rheumatoid Arthritis: Systematic Literature Review. ACTA ACUST UNITED AC 2018; 16:324-332. [PMID: 30241955 DOI: 10.1016/j.reuma.2018.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/14/2018] [Accepted: 07/19/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE 1) To systematically and critically review the evidence of combined therapy with synthetic disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis (RA); 2) To design practical recommendations on their use. METHODS A systematic literature review (SLR) was performed with a sensitive bibliographic search strategy in Medline, EMBASE and Cochrane Library. We selected randomized clinical trials that analyzed the efficacy and/or safety of 1) combined therapy of synthetic compared with sequential therapy of synthetic DMARD in early RA; and 2) combination of methotrexate+leflunomide or triple therapy with synthetic DMARD in established RA refractory to synthetic DMARD. Two reviewers made the first selection by title and abstract and 11 performed the selection after detailed review of the articles and data collection. The quality of the studies was evaluated with the Jadad scale. Based on the results, related recommendations were agreed upon in a nominal group meeting. RESULTS Ultimately, no articles were included in the SLR. The analysis of the reviewed articles demonstrated the effectiveness of the treatment with synthetic DMARD following a "treat to target" strategy in early RA patients, and of combination therapy of synthetic DMARD in established RA refractory to synthetic DMARD. This resulted in 6 recommendations concerning combination therapy with synthetic DMARD. CONCLUSIONS These recommendations aim to facilitate decision-making with the use of combined therapy with DMARD in RA.
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Affiliation(s)
- Jaime Calvo Alén
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, España.
| | - Trinidad Pérez
- Servicio de Reumatología, Hospital de León, León, España
| | - Susana Romero Yuste
- Servicio de Reumatología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, España
| | - Iván Ferraz-Amaro
- Servicio de Reumatología, Hospital Universitario de Canarias, Tenerife, España
| | | | | | | | - Juan Carlos Quevedo
- Servicio de Reumatología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | | | | | - Alejandro San Martín Álvarez
- Sección Reumatología, Clínica HLA Vistahermosa, Alicante, España; Sección Reumatología, Hospital HLA, Denia, España
| | | | - Raimon Sanmartí
- Servicio de Reumatología, Hospital Universitari Clínic, Barcelona, España
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Bello AE, Perkins EL, Jay R, Efthimiou P. Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis. Open Access Rheumatol 2017; 9:67-79. [PMID: 28435338 PMCID: PMC5386601 DOI: 10.2147/oarrr.s131668] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methotrexate (MTX) remains the cornerstone therapy for patients with rheumatoid arthritis (RA), with well-established safety and efficacy profiles and support in international guidelines. Clinical and radiologic results indicate benefits of MTX monotherapy and combination with other agents, yet patients may not receive optimal dosing, duration, or route of administration to maximize their response to this drug. This review highlights best practices for MTX use in RA patients. First, to improve the response to oral MTX, a high initial dose should be administered followed by rapid titration. Importantly, this approach does not appear to compromise safety or tolerability for patients. Treatment with oral MTX, with appropriate dose titration, then should be continued for at least 6 months (as long as the patient experiences some response to treatment within 3 months) to achieve an accurate assessment of treatment efficacy. If oral MTX treatment fails due to intolerability or inadequate response, the patient may be "rescued" by switching to subcutaneous delivery of MTX. Consideration should also be given to starting with subcutaneous MTX given its favorable bioavailability and pharmacodynamic profile over oral delivery. Either initiation of subcutaneous MTX therapy or switching from oral to subcutaneous administration improves persistence with treatment. Upon transition from oral to subcutaneous delivery, MTX dosage should be maintained, rather than increased, and titration should be performed as needed. Similarly, if another RA treatment is necessary to control the disease, the MTX dosage and route of administration should be maintained, with titration as needed.
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Affiliation(s)
| | | | - Randy Jay
- Arizona Arthritis & Rheumatology Associates, Phoenix, AZ
| | - Petros Efthimiou
- Division of Rheumatology, New York Methodist Hospital, Brooklyn, NY, USA
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Park SK, Park SH, Lee MY, Park JH, Jeong JH, Lee EK. Cost-effectiveness Analysis of Treatment Sequence Initiating With Etanercept Compared With Leflunomide in Rheumatoid Arthritis: Impact of Reduced Etanercept Cost With Patent Expiration in South Korea. Clin Ther 2016; 38:2430-2446.e3. [DOI: 10.1016/j.clinthera.2016.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/03/2016] [Accepted: 09/26/2016] [Indexed: 11/26/2022]
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Bae SC, Kim J, Choe JY, Park W, Lee SH, Park YB, Shim SC, Lee SS, Sung YK, Choi CB, Lee SR, Park H, Ahn Y. A phase III, multicentre, randomised, double-blind, active-controlled, parallel-group trial comparing safety and efficacy of HD203, with innovator etanercept, in combination with methotrexate, in patients with rheumatoid arthritis: the HERA study. Ann Rheum Dis 2016; 76:65-71. [DOI: 10.1136/annrheumdis-2015-207613] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 02/04/2016] [Accepted: 02/06/2016] [Indexed: 12/30/2022]
Abstract
ObjectivesTo evaluate equivalence in efficacy for rheumatoid arthritis (RA) and compare the safety of the biosimilar HD203 with innovator etanercept (ETN) plus methotrexate (MTX) (ClinicalTrials.govNCT01270997).MethodsPatients with active RA received 25 mg HD203 or ETN subcutaneously twice-weekly with MTX for 48 weeks in a phase III, multicentre, randomised, double-blind, parallel-group design. The primary end point was the proportion of patients achieving the American College of Rheumatology 20% response (ACR20) at week 24 for per-protocol study completer set (PPS). Secondary end points included ACR response criteria, ACRn, European League against Rheumatism (EULAR) response, change in Disease Activity Score 28 (DAS28), patient-reported outcomes, safety and immunogenicity.ResultsOf the 294 randomised patients (HD203, n=147; ETN, n=147), 233 comprised the 24-week PPS (n=115 and 118, respectively). ACR20 at week 24 was achieved by 83.48% and 81.36% of PPS patients, respectively, demonstrating equivalent efficacy within predefined margins of ±20% (treatment difference 2.12%, 95% CI −7.65% to 11.89%). Outcomes for secondary end points were consistent with the primary efficacy findings. Groups were comparable for overall incidences of treatment-emergent (all-causality) adverse events (AEs) (HD203 113 (76.9%) vs ETN 114 (78.1%) (p=0.804)), adverse drug reactions, serious AEs and discontinuations due to AEs. Few patients (HD203, n=8; ETN, n=3) tested positive for anti-drug antibodies.ConclusionThe study met the primary objective of demonstrating equivalent efficacy of HD203 and ETN. HD203 was well tolerated, with safety comparable with ETN in this population of patients with RA.Trial registration numberNCT01270997; Results.
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