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Álvaro-Gracia Álvaro JM, Díaz Del Campo Fontecha P, Andréu Sánchez JL, Balsa Criado A, Cáliz Cáliz R, Castrejón Fernández I, Corominas H, Gómez Puerta JA, Manrique Arija S, Mena Vázquez N, Ortiz García A, Plasencia Rodríguez C, Silva Fernández L, Tornero Molina J. Update of the Consensus Statement of the Spanish Society of Rheumatology on the use of biological and synthetic targeted therapies in rheumatoid arthritis. REUMATOLOGIA CLINICA 2024; 20:423-439. [PMID: 39341701 DOI: 10.1016/j.reumae.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/24/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVE To update the consensus document of the Spanish Society of Rheumatology (SER) regarding the use of targeted biological and synthetic therapies in rheumatoid arthritis (RA) with the aim of assisting clinicians in their therapeutic decisions. METHODS A panel of 13 experts was assembled through an open call by SER. We employed a mixed adaptation-elaboration-update methodology starting from the 2015 Consensus Document of the Spanish Society of Rheumatology on the use of biological therapies in RA. Starting with systematic reviews (SR) of recommendations from EULAR 2019, American College of Rheumatology 2021, and GUIPCAR 2017, we updated the search strategies for the PICO questions of GUIPCAR. An additional SR was conducted on demyelinating disease in relation to targeted biological and synthetic therapies. Following the analysis of evidence by different panelists, consensus on the wording and level of agreement for each recommendation was reached in a face-to-face meeting. RESULTS The panel established 5 general principles and 15 recommendations on the management of RA. These encompassed crucial aspects such as the importance of early treatment, therapeutic goals in RA, monitoring frequency, the use of glucocorticoids, the application of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), biological DMARDs (bDMARDs), and targeted synthetic DMARDs. Additionally, recommendations on dose reduction of these drugs in stable patients were included. This update also features recommendations on the use of bDMARDs and Janus Kinase inhibitors in some specific clinical situations, such as patients with lung disease, a history of cancer, heart failure, or demyelinating disease. CONCLUSIONS This update provides recommendations on key aspects in the management of RA using targeted biological and synthetic therapies.
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Affiliation(s)
- José María Álvaro-Gracia Álvaro
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, IiSGM, Universidad Complutense Madrid, Madrid, Spain.
| | | | - José Luis Andréu Sánchez
- Servicio de Reumatología, H.U. Puerta de Hierro Majadahonda, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | | | | | - Isabel Castrejón Fernández
- Servicio de Reumatología, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital Gregorio Marañón, Departamento de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Hèctor Corominas
- Servicio de Reumatología, Hospital Universitari de la Santa Creu i Sant Pau & Hospital Dos de Maig, Barcelona, Spain
| | | | - Sara Manrique Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, UGC de Reumatología, Hospital Regional Universitario de Málaga, Departamento de Medicina, Universidad de Málaga, Málaga, Spain
| | - Natalia Mena Vázquez
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
| | - Ana Ortiz García
- Servicio de Reumatología, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Lucía Silva Fernández
- Servicio de Reumatología, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Jesús Tornero Molina
- Servicio de Reumatología, Hospital Universitario de Guadalajara, Departamento de Medicina, Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
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Sparks JA, Harrold LR, Simon TA, Wittstock K, Kelly S, Lozenski K, Khaychuk V, Michaud K. Comparative effectiveness of treatments for rheumatoid arthritis in clinical practice: A systematic review. Semin Arthritis Rheum 2023; 62:152249. [PMID: 37573754 DOI: 10.1016/j.semarthrit.2023.152249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 07/11/2023] [Accepted: 07/24/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To assess real-world comparative effectiveness studies of biologic (b) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARDs) in adults with rheumatoid arthritis (RA) through a systematic review. METHODS We searched Medline for journal articles (2001-2021) and Embase® for abstracts presented at the European Alliance of Associations for Rheumatology and American College of Rheumatology (ACR) 2020 and 2021 annual meetings on non-randomized studies comparing the effectiveness of b/tsDMARDs using ACR-recommended disease activity measures, measures of functional status, and patient-reported outcomes (HAQ, PROMIS PF, patient pain, Patient and Physician Global Assessment of disease activity). Methodological heterogeneity between studies precluded meta-analyses. Risk of bias was assessed using the Cochrane Risk Of Bias In Non-randomized Studies of Interventions-I tool. RESULTS Of 1283 records screened, 68 were selected for data extraction, of which 1 was excluded due to critical risk of bias. Most studies were multicenter observational cohort/registry studies (n = 60) and were published between 2011 and 2021 (n = 60). Mean or median reported RA duration was between 6 and 15 years. Disease Activity Score in 28 joints (46 studies), Clinical Disease Activity Index (37 studies), and Health Assessment Questionnaire-Disability Index (32 studies) were the most common outcomes used in clinical practice, with regional differences identified. The most common comparison was between tumor necrosis factor inhibitors (TNFis) and non-TNFi bDMARDs (35 studies). There were no evident differences between b/tsDMARDs in clinical effectiveness. CONCLUSION This systematic review summarizing real-world evidence from a very large number of global studies found there are many effective options for the treatment of RA, but relatively less evidence to support the use of any one b/tsDMARD or drug class over another. Treatment for patients with RA should be tailored to suit individual clinical profiles. Further research is needed to identify whether specific patient subgroups may benefit from specific drug classes.
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Affiliation(s)
- Jeffrey A Sparks
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Leslie R Harrold
- CorEvitas, LLC, Waltham, MA, USA; University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | | | | | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA; FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA.
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Zian Z, Berry SPDG, Bahmaie N, Ghotbi D, Kashif A, Madkaikar M, Bargir UA, Abdullahi H, Khan H, Azizi G. The clinical efficacy of Rituximab administration in autoimmunity disorders, primary immunodeficiency diseases and malignancies. Int Immunopharmacol 2021; 95:107565. [PMID: 33773205 DOI: 10.1016/j.intimp.2021.107565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
Rituximab (RTX), as a monoclonal antibody-based immunotherapeutic intervention targeting CD20 on B cells, has proven efficacy in the treatment of patients with some immune-mediated diseases. In the present review, we provided information on the immunobiological mechanisms of signaling for RTX and its clinical applications, according to the immune-pathophysiology involved in the microenvironment of multiple diseases. We highlighted combination therapy, dose schedules, and laboratory monitoring, as well as the associated common and rare side effects to avoid. We also discussed the efficacy and safety of RTX-based therapeutic strategies and whether RTX therapy can be used as a promising treatment regimen for autoimmune diseases, primary immunodeficiency diseases, and malignancies. Our review highlights and supports the importance of collaboration between basic medical researchers and clinical specialists when considering the use of RTX in the treatment of various immune-mediated disorders.
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Affiliation(s)
- Zeineb Zian
- Biomedical Genomics and Oncogenetics Research Laboratory, Faculty of Sciences and Techniques of Tangier, P.B. 416, Abdelmalek Essaadi University, Tetouan, Morocco
| | - S P Déo-Gracias Berry
- Centre de Recherches Médicales (CERMEL) de Lambaréné, B.P: 242, Gabon; Technical University of Munich, 80333, Germany
| | - Nazila Bahmaie
- Department of Allergy and Immunology, Faculty of Medicine, Graduate School of Health Science, Near East University (NEU), Nicosia, 99138, Northern Cyprus, Cyprus
| | - Dana Ghotbi
- Faculty of Biological Sciences, University of Kharazmi, Tehran 14911-15719, Iran
| | - Ali Kashif
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Manisha Madkaikar
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology, Mumbai 400070, India
| | - Umair Ahmed Bargir
- Department of Pediatric Immunology and Leukocyte Biology, ICMR-National Institute of Immunohaematology, Mumbai 400070, India
| | - Hamisu Abdullahi
- Department of Immunology, School of Medical Laboratory Sciences, Usmanu Danfodiyo University Sokoto, 840232, Nigeria
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj 3149779453, Iran.
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Bonek K, Roszkowski L, Massalska M, Maslinski W, Ciechomska M. Biologic Drugs for Rheumatoid Arthritis in the Context of Biosimilars, Genetics, Epigenetics and COVID-19 Treatment. Cells 2021; 10:323. [PMID: 33557301 PMCID: PMC7914976 DOI: 10.3390/cells10020323] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 01/08/2023] Open
Abstract
Rheumatoid arthritis (RA) affects around 1.2% of the adult population. RA is one of the main reasons for work disability and premature retirement, thus substantially increasing social and economic burden. Biological disease-modifying antirheumatic drugs (bDMARDs) were shown to be an effective therapy especially in those rheumatoid arthritis (RA) patients, who did not adequately respond to conventional synthetic DMARD therapy. However, despite the proven efficacy, the high cost of the therapy resulted in limitation of the widespread use and unequal access to the care. The introduction of biosimilars, which are much cheaper relative to original drugs, may facilitate the achievement of the therapy by a much broader spectrum of patients. In this review we present the properties of original biologic agents based on cytokine-targeted (blockers of TNF, IL-6, IL-1, GM-CSF) and cell-targeted therapies (aimed to inhibit T cells and B cells properties) as well as biosimilars used in rheumatology. We also analyze the latest update of bDMARDs' possible influence on DNA methylation, miRNA expression and histone modification in RA patients, what might be the important factors toward precise and personalized RA treatment. In addition, during the COVID-19 outbreak, we discuss the usage of biologicals in context of effective and safe COVID-19 treatment. Therefore, early diagnosing along with therapeutic intervention based on personalized drugs targeting disease-specific genes is still needed to relieve symptoms and to improve the quality of life of RA patients.
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Affiliation(s)
- Krzysztof Bonek
- Department of Rheumatology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (K.B.); (L.R.)
| | - Leszek Roszkowski
- Department of Rheumatology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (K.B.); (L.R.)
| | - Magdalena Massalska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (M.M.); (W.M.)
| | - Wlodzimierz Maslinski
- Department of Pathophysiology and Immunology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (M.M.); (W.M.)
| | - Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics Rheumatology and Rehabilitation, 02-635 Warsaw, Poland; (M.M.); (W.M.)
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Roodenrijs NMT, Hamar A, Kedves M, Nagy G, van Laar JM, van der Heijde D, Welsing PMJ. Pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of difficult-to-treat rheumatoid arthritis. RMD Open 2021; 7:e001512. [PMID: 33419871 PMCID: PMC7798678 DOI: 10.1136/rmdopen-2020-001512] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To summarise, by a systematic literature review (SLR), the evidence regarding pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis (D2T RA), informing the EULAR recommendations for the management of D2T RA. METHODS PubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised. RESULTS Two hundred seven (207) papers studied therapeutic strategies. Limited evidence was found on effective and safe disease-modifying antirheumatic drugs (DMARDs) in patients with comorbidities and other contraindications that limit DMARD options (patients with obesity, hepatitis B and C, risk of venous thromboembolisms, pregnancy and lactation). In patients who previously failed biological (b-)DMARDs, all currently used b/targeted synthetic (ts-)DMARDs were found to be more effective than placebo. In patients who previously failed a tumour necrosis factor inhibitor (TNFi), there was a tendency of non-TNFi bDMARDs to be more effective than TNFis. Generally, effectiveness decreased in patients who previously failed a higher number of bDMARDs. Additionally, exercise, psychological, educational and self-management interventions were found to improve non-inflammatory complaints (mainly functional disability, pain, fatigue), education to improve goal setting, and self-management programmes, educational and psychological interventions to improve self-management.The identified evidence had several limitations: (1) no studies were found in patients with D2T RA specifically, (2) heterogeneous outcome criteria were used and (3) most studies had a moderate or high risk of bias. CONCLUSIONS This SLR underscores the scarcity of high-quality evidence on the pharmacological and non-pharmacological treatment of patients with D2T RA. Effectiveness of b/tsDMARDs decreased in RA patients who had failed a higher number of bDMARDs and a subsequent b/tsDMARD of a previously not targeted mechanism of action was somewhat more effective. Additionally, a beneficial effect of non-pharmacological interventions was found for improvement of non-inflammatory complaints, goal setting and self-management.
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Affiliation(s)
- Nadia M T Roodenrijs
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Attila Hamar
- Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Melinda Kedves
- Rheumatology, Bacs-Kiskun Megyei Korhaz, Kecskemet, Hungary
| | - György Nagy
- Genetics, Cell- and Immunobiology & Rheumatology & Clinical Rheumatology, Semmelweis University, Budapest, Hungary
| | - Jacob M van Laar
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Paco M J Welsing
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Zhao SS, Lyu H, Solomon DH, Yoshida K. Improving rheumatoid arthritis comparative effectiveness research through causal inference principles: systematic review using a target trial emulation framework. Ann Rheum Dis 2020; 79:883-890. [PMID: 32381560 PMCID: PMC8693471 DOI: 10.1136/annrheumdis-2020-217200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Target trial emulation is an intuitive design framework that encourages investigators to formulate their comparative effectiveness research (CER) question as a hypothetical randomised controlled trial (RCT). Our aim was to systematically review CER studies in rheumatoid arthritis (RA) to provide examples of design limitations that could be avoided using target trial emulation, and how these limitations might introduce bias. METHODS We searched for head-to-head CER studies of biologic disease modifying anti-rheumatic drugs (DMARDs) in RA. Study designs were reviewed for seven components of the target trial emulation framework: eligibility criteria, treatment strategies, assignment procedures, follow-up period, outcome, causal contrasts of interest (ie, intention-to-treat (ITT) or per-protocol effect) and analysis plan. Hypothetical trials corresponding to the reported methods were assessed to identify design limitations that would have been avoided with an explicit target trial protocol. Analysis of the primary effectiveness outcome was chosen where multiple analyses were performed. RESULTS We found 31 CER studies, of which 29 (94%) had at least one design limitation belonging to seven components. The most common limitations related to: (1) eligibility criteria: 19/31 (61%) studies used post-baseline information to define baseline eligibility; (2) causal contrasts: 25 (81%) did not define whether ITT or per-protocol effects were estimated and (3) assignment procedures: 13 (42%) studies did not account for confounding by indication or relied solely on statistical confounder selection. CONCLUSIONS Design limitations were found in 94% of observational CER studies in RA. Target trial emulation is a structured approach for designing observational CER studies that helps to avoid potential sources of bias.
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Affiliation(s)
- Sizheng Steven Zhao
- Musculoskeletal Biology, Institute of Lifecourse and Medical Sciences, University of Liverpool, Liverpool, UK
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Houchen Lyu
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, China
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kazuki Yoshida
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Youssef P, Marcal B, Button P, Truman M, Bird P, Griffiths H, Roberts L, Tymms K, Littlejohn G. Reasons for Biologic and Targeted Synthetic Disease-modifying Antirheumatic Drug Cessation and Persistence of Second-line Treatment in a Rheumatoid Arthritis Dataset. J Rheumatol 2019; 47:1174-1181. [PMID: 31787605 DOI: 10.3899/jrheum.190535] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide real-world evidence about the reasons why Australian rheumatologists cease biologic (b) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) when treating patients with rheumatoid arthritis (RA), and to assess (1) the primary failure rate for first-line treatment, and (2) the persistence on second-line treatments in patients who stopped first-line tumor necrosis factor inhibitors (TNFi). METHODS This is a multicenter retrospective, noninterventional study of patients with RA enrolled in the Australian Optimising Patient outcome in Australian RheumatoLogy (OPAL) dataset with a start date of b/tsDMARD between August 1, 2010, and June 30, 2017. Primary failure was defined as stopping treatment within 6 months of treatment initiation. RESULTS Data from 7740 patients were analyzed; 6914 patients received first-line b/tsDMARD. First-line treatment was stopped in 3383 (49%) patients; 1263 (37%) were classified as primary failures. The most common reason was "lack of efficacy" (947/2656, 36%). Of the patients who stopped first-line TNFi, 43% (1111/2560) received second-line TNFi, which resulted in the shortest median time to stopping second-line treatment (11 months, 95% CI 9-12) compared with non-TNFi. The longest second-line median treatment duration after first-line TNFi was for patients receiving rituximab (39 months, 95% CI 27-74). CONCLUSION A large proportion of patients who stopped first-line TNFi therapy received another TNFi despite evidence for longer treatment persistence on second-line b/tsDMARD with a different mode of action. Lack of efficacy was recorded as the most common reason for making a switch in first-line treatment of patients with RA.
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Affiliation(s)
- Peter Youssef
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia. .,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University.
| | - Bruno Marcal
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
| | - Peter Button
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
| | - Matt Truman
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
| | - Paul Bird
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
| | - Hedley Griffiths
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
| | - Lynden Roberts
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
| | - Kathleen Tymms
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
| | - Geoff Littlejohn
- From the Royal Prince Alfred Hospital, Camperdown; University of Sydney, Sydney; Roche Products Pty Ltd., Sydney; OzBiostat Pty Ltd., Sydney; University of New South Wales, Sydney; Barwon Rheumatology Service, Geelong; Monash Rheumatology, Clayton; Canberra Rheumatology, Canberra; Monash University, Clayton, Australia.,P. Youssef, MD, Professor, Royal Prince Alfred Hospital, and University of Sydney; B. Marcal, BPharm, Roche Products Pty Ltd.; P. Button, MSc, OzBiostat Pty Ltd.; M. Truman, MSc, OzBiostat Pty Ltd.; P. Bird, MD, PhD, Grad Dip MRI, University of New South Wales; H. Griffiths, MD, Barwon Rheumatology Service; L. Roberts, MD, PhD, Associate Professor, Monash Rheumatology; K. Tymms, MD, Associate Professor, Canberra Rheumatology; G. Littlejohn, MD, Professor, Monash University
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Abatacept Monotherapy Versus Abatacept Plus Methotrexate for Treatment-Refractory Rheumatoid Arthritis. Am J Ther 2019; 26:e358-e363. [PMID: 29023282 DOI: 10.1097/mjt.0000000000000645] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Methotrexate combination therapy improves abatacept efficacy as a first-line biologic agent for the treatment of rheumatoid arthritis, but it is unclear when abatacept is used later on, particularly after non-TNF inhibitor (TNFi) failure. STUDY QUESTION The objective of this study was to determine whether treatment response after non-TNFi inadequate response is different in patients with rheumatoid arthritis (RA) treated with abatacept in combination with or not with methotrexate. METHODS Patients treated with abatacept monotherapy or in combination with methotrexate after non-TNFi failure were included. RESULTS Data from 46 patients aged 56 years [49-61] with 12 years [8-16] of disease duration were examined. Rituximab was the treatment used in the previous line for 75.0% of the combination therapy group (15/20) and 34.6% (9/26) in the monotherapy group. At 12 months, 38.5% (10/26) of patients were in good-to-moderate EULAR response in the monotherapy group compared with 25.0% (5/20) in the combination therapy group (P = 0.33). Treatment persistence at 12 months was 61.5% (16/26) in the monotherapy group and 35.0% (7/20) in the combination therapy group (P = 0.07). CONCLUSIONS Adding methotrexate to abatacept did not improve treatment response in patients with RA after non-TNFi inadequate response.
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Elmedany SH, Mohamed AE, Galil SMA. Efficacy and safety profile of intravenous tocilizumab versus intravenous abatacept in treating female Saudi Arabian patients with active moderate-to-severe rheumatoid arthritis. Clin Rheumatol 2019; 38:2109-2117. [PMID: 30915650 DOI: 10.1007/s10067-019-04508-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/06/2019] [Accepted: 03/07/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To compare the efficacy and safety of tocilizumab with those of abatacept in patients with active rheumatoid arthritis not responding to anti-tumor necrosis factor therapy. METHODS A prospective, open-label study was carried out on adult females with moderate-to-severe rheumatoid arthritis. Patients were randomly assigned to receive either intravenous tocilizumab or abatacept treatment. History taking, clinical examination, and laboratory evaluation were done at baseline and during a 24-week period of follow-up. Disease activity was calculated using the DAS28-ESR score. The incidence of accompanying adverse events was evaluated and all statistical analyses were performed by InStat. RESULTS One hundred thirty-two patients were enrolled and classified randomly into the tocilizumab (n = 68) and abatacept (n = 64) groups. By week 24, the mean DAS28-ESR was significantly reduced in both groups (P < 0.0001) in association with significant reductions in CRP, ESR, and HAQ scores. No significant difference in the incidence rate of adverse effects appeared between both study groups. However, there were marked declines in the hemoglobin levels (P = 0.003) and neutrophil count (P = 0.002) together with significant elevations in systolic blood pressure (P = 0.002), liver enzymes (P = 0.001), total cholesterol (P = 0.001), and high-density lipoproteins (P = 0.002) in the tocilizumab group compared with the abatacept group. CONCLUSION Both intravenous abatacept and tocilizumab significantly decreased the disease activity and improved the physical function in rheumatoid arthritis patients who failed to respond to anti-tumor necrosis factor therapy. Although the efficacy of both drugs was similar, abatacept showed a more promising short-term safety profile since it was associated with less adverse effects and better laboratory outcomes.
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Affiliation(s)
- Samah Hamdy Elmedany
- Physical Medicine, Rheumatology and Rehabilitation Department, Tanta University, El-Giesh Street, Tanta, 31111, Egypt
| | - Aly Elsayed Mohamed
- Physical Medicine, Rheumatology and Rehabilitation Department, Suez Canal University, Ismailia, Egypt
| | - Sahar Mahfouz Abdel Galil
- Rheumatology & Rehabilitation Department, Faculty of Medicine, Zagazig University, University Street, Zagazig, 44519, Egypt. .,Medicine Department, College of Medicine, Umm Al-Qura University, El-Abdia, Makkah province, 21955, Saudi Arabia.
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Gottenberg JE, Morel J, Perrodeau E, Bardin T, Combe B, Dougados M, Flipo RM, Saraux A, Schaeverbeke T, Sibilia J, Soubrier M, Vittecoq O, Baron G, Constantin A, Ravaud P, Mariette X. Comparative effectiveness of rituximab, abatacept, and tocilizumab in adults with rheumatoid arthritis and inadequate response to TNF inhibitors: prospective cohort study. BMJ 2019; 364:l67. [PMID: 30679233 PMCID: PMC6344892 DOI: 10.1136/bmj.l67] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of three non-tumour necrosis factor (TNF) α inhibitors (rituximab, abatacept, and tocilizumab) in the treatment of rheumatoid arthritis. DESIGN Population based prospective study. SETTING 53 university and 54 non-university clinical centres in France. PARTICIPANTS 3162 adults (>18 years) with rheumatoid arthritis according to 1987 American College of Rheumatology criteria, enrolled in one of the three French Society of Rheumatology registries; who had no severe cardiovascular disease, active or severe infections, or severe immunodeficiency, with follow-up of at least 24 months. INTERVENTION Initiation of intravenous rituximab, abatacept, or tocilizumab for rheumatoid arthritis. MAIN OUTCOME MEASURE The primary outcome was drug retention without failure at 24 months. Failure was defined as all cause death; discontinuation of rituximab, abatacept, or tocilizumab; initiation of a new biologic or a combination of conventional disease modifying antirheumatic drugs; or increase in corticosteroid dose >10 mg/d compared with baseline at two successive visits. Because of non-proportional hazards, treatment effects are presented as life expectancy difference without failure (LEDwf), which measures the difference between average duration of survival without failure. RESULTS Average durations of survival without failure were 19.8 months for rituximab, 15.6 months for abatacept, and 19.1 months for tocilizumab. Average durations were greater with rituximab (LEDwf 4.1, 95% confidence interval 3.1 to 5.2) and tocilizumab (3.5, 2.1 to 5.0) than with abatacept, and uncertainty about tocilizumab compared with rituximab was substantial (-0.7, -1.9 to 0.5). No evidence was found of difference between treatments for mean duration of survival without death, presence of cancer or serious infections, or major adverse cardiovascular events. CONCLUSION Among adults with refractory rheumatoid arthritis followed-up in routine practice, rituximab and tocilizumab were associated with greater improvements in outcomes at two years compared with abatacept.
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MESH Headings
- Abatacept/administration & dosage
- Abatacept/adverse effects
- Adult
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antirheumatic Agents/administration & dosage
- Antirheumatic Agents/adverse effects
- Arthritis, Rheumatoid/diagnosis
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/epidemiology
- Biological Factors/therapeutic use
- Cohort Studies
- Drug Monitoring/methods
- Drug Monitoring/statistics & numerical data
- Drug Resistance
- Drug Therapy, Combination/methods
- Drug Therapy, Combination/statistics & numerical data
- Female
- France/epidemiology
- Humans
- Male
- Outcome Assessment, Health Care
- Prospective Studies
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Survival Analysis
- Tumor Necrosis Factor-alpha/antagonists & inhibitors
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Affiliation(s)
- Jacques-Eric Gottenberg
- Department of Rheumatology, 1 avenue Molière, Strasbourg University Hospital, National Centre For Rare Systemic Autoimmune Diseases, 67000 Strasbourg, France
- CNRS UPR3572, Immunologie, Immunopathologie et Chimie Thérapeutique, Institut de Biologie Moléculaire et Cellulaire, 15 rue René Descartes, Strasbourg University, 67000 Strasbourg, France
| | - Jacques Morel
- Department of Rheumatology, Montpellier University Hospital, Montpellier, France
| | - Elodie Perrodeau
- Department of Epidemiology and Public Health, Hotel Dieu, Assistance Publique des Hôpitaux de Paris (APHP), Paris, France
| | - Thomas Bardin
- Department of Rheumatology, Lariboisière Hospital, Paris, France
| | - Bernard Combe
- Department of Rheumatology, Montpellier University Hospital, Montpellier, France
| | | | - Rene-Marc Flipo
- Department of Rheumatology, University Hospital, Lille, France
| | - Alain Saraux
- Department of Rheumatology, University Hospital, Brest, France
| | | | - Jean Sibilia
- Department of Rheumatology, 1 avenue Molière, Strasbourg University Hospital, National Centre For Rare Systemic Autoimmune Diseases, 67000 Strasbourg, France
| | - Martin Soubrier
- Department of Rheumatology, University Hospital, Clermont Ferrand, France
| | | | - Gabriel Baron
- Department of Epidemiology and Public Health, Hotel Dieu, Assistance Publique des Hôpitaux de Paris (APHP), Paris, France
| | | | - Philippe Ravaud
- Department of Epidemiology and Public Health, Hotel Dieu, Assistance Publique des Hôpitaux de Paris (APHP), Paris, France
| | - Xavier Mariette
- Department of Rheumatology, Université Paris Sud, AP-HP, Hôpitaux Universitaires Paris-Sud, Center for Immunology of viral infections and autoimmune diseases (IMVA), INSERM U1184, Le Kremlin Bicêtre, France
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Kim SC, Solomon DH, Rogers JR, Gale S, Klearman M, Sarsour K, Schneeweiss S. No difference in cardiovascular risk of tocilizumab versus abatacept for rheumatoid arthritis: A multi-database cohort study. Semin Arthritis Rheum 2018; 48:399-405. [PMID: 29673963 DOI: 10.1016/j.semarthrit.2018.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/02/2018] [Accepted: 03/21/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES While tocilizumab may increase serum lipid levels, recent studies do not suggest a link between tocilizumab use and clinical cardiovascular risk in patients with rheumatoid arthritis (RA). METHODS To compare cardiovascular safety of tocilizumab with abatacept, we conducted a cohort study using data from Medicare (2010-2013), IMS PharMetrics (2011-2014) and MarketScan (2011-6/2015). RA patients aged ≥18 years who newly started tocilizumab or abatacept entered the cohort on the day of their first use of tocilizumab or abatacept after a continuous enrollment period for ≥365 days. The primary outcome was a composite cardiovascular endpoint of hospitalization for myocardial infarction or stroke. To control for more than 60 confounders, tocilizumab starters were propensity score (PS)-matched to abatacept starters with a variable ratio of 1:3 within each database. A fixed-effects model combined database-specific hazard ratios (HR). RESULTS We included 6237 tocilizumab starters PS-matched to 14,685 abatacept starters in all three databases. Mean age was 72 years in Medicare, 51 in PharMetrics and 53 in MarketScan. The incidence rate of the composite cardiovascular events per 100 person-years ranged from 0.37 (PharMetrics) to 1.64 (Medicare) in the tocilizumab group and from 0.59 (PharMetrics) to 1.69 (Medicare) in the abatacept group. The risk of the composite cardiovascular events was similar between the two groups across all three databases, with a combined HR of 0.82 (95% CI: 0.55-1.22) in tocilizumab versus abatacept starters. CONCLUSIONS This multi-database cohort study found no difference in the risk of cardiovascular events in RA patients who newly started tocilizumab versus abatacept.
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Affiliation(s)
- Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120; Division of Rheumatology, Immunology and Allergy; Brigham and Women's Hospital, Boston, MA 02115.
| | - Daniel H Solomon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120; Division of Rheumatology, Immunology and Allergy; Brigham and Women's Hospital, Boston, MA 02115
| | - James R Rogers
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120
| | - Sara Gale
- Genentech, a Member of the Roche Group, South San Francisco, CA 94080
| | - Micki Klearman
- Genentech, a Member of the Roche Group, South San Francisco, CA 94080
| | - Khaled Sarsour
- Genentech, a Member of the Roche Group, South San Francisco, CA 94080
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120
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Favalli EG, Raimondo MG, Becciolini A, Crotti C, Biggioggero M, Caporali R. The management of first-line biologic therapy failures in rheumatoid arthritis: Current practice and future perspectives. Autoimmun Rev 2017; 16:1185-1195. [DOI: 10.1016/j.autrev.2017.10.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/31/2017] [Indexed: 12/20/2022]
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Cantini F, Niccoli L, Nannini C, Cassarà E, Kaloudi O, Giulio Favalli E, Becciolini A, Benucci M, Gobbi FL, Guiducci S, Foti R, Mosca M, Goletti D. Second-line biologic therapy optimization in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Semin Arthritis Rheum 2017; 47:183-192. [PMID: 28413099 DOI: 10.1016/j.semarthrit.2017.03.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/05/2017] [Accepted: 03/15/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The Italian board for the TAilored BIOlogic therapy (ITABIO) reviewed the most consistent literature to indicate the best strategy for the second-line biologic choice in patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA). METHODS Systematic review of the literature to identify English-language articles on efficacy of second-line biologic choice in RA, PsA, and ankylosing spondylitis (AS). Data were extracted from available randomized, controlled trials, national biologic registries, national healthcare databases, post-marketing surveys, and open-label observational studies. RESULTS Some previously stated variables, including the patients׳ preference, the indication for anti-tumor necrosis factor (TNF) monotherapy in potential childbearing women, and the intravenous route with dose titration in obese subjects resulted valid for all the three rheumatic conditions. In RA, golimumab as second-line biologic has the highest level of evidence in anti-TNF failure. The switching strategy is preferable for responder patients who experience an adverse event, whereas serious or class-specific side effects should be managed by the choice of a differently targeted drug. Secondary inadequate response to etanercept (ETN) should be treated with a biologic agent other than anti-TNF. After two or more anti-TNF failures, the swapping to a different mode of action is recommended. Among non-anti-TNF targeted biologics, to date rituximab (RTX) and tocilizumab (TCZ) have the strongest evidence of efficacy in the treatment of anti-TNF failures. In PsA and AS patients failing the first anti-TNF, the switch strategy to a second is advisable, taking in account the evidence of adalimumab efficacy in patients with uveitis. The severity of psoriasis, of articular involvement, and the predominance of enthesitis and/or dactylitis may drive the choice toward ustekinumab or secukinumab in PsA, and the latter in AS. CONCLUSION Taking in account the paucity of controlled trials, second-line biologic therapy may be reasonably optimized in patients with RA, SpA, and PsA.
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Affiliation(s)
- Fabrizio Cantini
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy.
| | - Laura Niccoli
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | - Carlotta Nannini
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | - Emanuele Cassarà
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | - Olga Kaloudi
- Division of Rheumatology, Hospital of Prato, Piazza Ospedale, 1, 59100 Prato, Italy
| | | | | | | | | | - Serena Guiducci
- Department of Biomedicine, Section of Rheumatology, University of Florence, Florence, Italy
| | - Rosario Foti
- Rheumatology Unit, Vittorio-Emanuele University Hospital of Catania, Catania, Italy
| | - Marta Mosca
- UO di Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
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