Methotrexate in combination with disease-modifying antirheumatic drugs, most notably infliximab, was effective in retarding X-ray progression in patients with rheumatoid arthritis, while tocilizumab ranked best as a biologic monotherapy, according to study results.
Researchers in Tasmania, Australia, conducted a meta-analysis of 18 randomized, double blind trials to review the efficacy of biologic combination therapy in rheumatoid arthritis (RA) patients (n=4,620) and biologics alone (n=2,191). They ranked and compared treatments after calculating standardized mean differences and odds ratios for worsening X-ray scores. Primary outcomes were radiographic scoring of bone erosion and joint space narrowing.
In total X-ray scores infliximab/methotrexate vs. methotrexate alone ranked best of the disease-modifying antirheumatic drugs (DMARDs) with a standardized mean difference (SMD) of –0.63 (95% CI, –0.87 to –0.38). The combination also showed the best odds of slowing progression of radiographic damage (OR=0.07; 95% CI, 0.02-0.29). The DMARDs etanercept, adalimumab, certolizumab, tocilizumab and rituximab used in combination with methotrexate effectively slowed X-ray progression compared with methotrexate alone.
As monotherapy, patients treated with tocilizumab showed better SMD values for total X-ray scores (–0.43; 95% CI, –0.65 to –0.20) and odds for worsening X-ray scores (OR=0.50; 95% CI, 0.31-0.82) than methotrexate alone. Adalimumab and etanercept also achieved better results than methotrexate.
Researchers found golimumab ineffective as biologic monotherapy in both outcome measures, and in combination with methotrexate it showed no effect on SMD.
“This quantitative overview provides convincing evidence that, when combined with methotrexate, most biologics are effective at slowing X-ray progression assessed by mean change or odds of progression,” the researchers concluded. “In a [RA] patient who can take methotrexate, all biologic DMARDs [with the possible exception of infliximab and golimumab] have similar efficacy, thus can be selected without reference to their effect in radiologic progression. In the not uncommon patient who cannot take methotrexate, the data favor tocilizumab as the treatment of choice at this time.”
Disclosure: See the study for a full list of relevant disclosures.