Head-to-Head Test of Biologic Agents Finds Similar Efficacy

A head-to-head test of seven biologic agents finds that all are similarly effective in treating rheumatoid arthritis. The new study, presented November 8 at the annual meeting of the American College of Rheumatology in San Francisco, found no differences in efficacy between abatacept, adalimumab, certolizumab, etanercept, infliximab, rituximab and tocilizumab in a real-world registry of patients. "There is virtually no difference between them," said study leader Yusuf Yazici, MD, a rheumatologist at NYU Langone Medical Center. Thus, physicians should base the choice of biologic on other factors like patient risk profile, preferences and comorbidities, Yazici said. Though there are a dozen biologic agents on the market, there have been few direct comparisons between these drugs, Yazici said. Thus, physicians haven't had clear guidelines as to which biologic to pick for the 50 percent of patients who don't respond to initial methotrexate therapy. Earlier evidence has suggested that all of these drugs are fairly similar in their efficacy, despite different modes of function. Yazici and his colleagues studied this question in a real-world sample: a database of patients treated for rheumatoid arthritis at NYU Langone. The database included 1,789 treatment observations for 316 patients. The researchers used the Routine Assessment of Patient Index Data 3 (RAPID3) to gauge efficacy. This patient-report scale correlates to other validated rheumatoid arthritis scales, including the Disease Activity Score 28 (DAS28) and the Clinical Disease Activity Index (CDAI). Overall, there were no statistically significant differences in the time to first response or the overall response between any of the biologics. (Time to first response was defined as a 3.6-point improvement on the 30-point RAPID3 scale.) There were a few statistically non-significant trends, showing slightly increased efficacy of adalimumab and tocilizumab compared to infliximab, and slightly decreased efficacy to certolizumab compared to infliximab, but those findings did not strongly suggest differences between the drugs, Yazici said. In any registry study, referral bias is possible, Yazici said, but the researchers did adjust for age, gender and disease activity to try to control for such bias. The group's findings also complement research done by others, he said. "As far as I know from the published data, we all fall into the same range of responses," he said. "So that makes us more confident that what we're seeing is a true effect." For most patients, the first-choice biologic will be a matter of preference, Yazici said. Do they prefer an infusion or an injection? How often do they want to get the treatment? Are there side effects or comorbidities to consider? Most of the drugs are similar in price, he said. The exception is infliximab. For that drug, the recommended dose prices out similarly to other biologics, but about 70 percent of patients require a higher dose, increasing the cost. The new research looked only at the first biologic patients tried, Yazici said. He and his colleagues next plan to study drug-switching to find out which agent physicians and patients choose as a second choice and if there are differences in response based on their first-choice biologic. The ACR abstract presenting the trial data was highlighted for a discussion by the Rheumatology Journal Club on Dec. 10 by a group of rheumatologists polled on Twitter.  Led by Christopher E. Collins, MD, an associate professor of medicine at Georgetown University Medical Center and a member of the Rheumatology Network Editorial Board, the group noted that the “take home message here is that it affirms what we all kind of felt anyway … most biologics are effective equally.”  

References:

Singh, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care & Research DOI 10.1002/acr.22783 VC 2015, American College of Rheumatology.

Yazici Y, Bernstein H, Swearingen C. Comparative Effectiveness and Time to Response Among Abatacept, Adalimumab, Certolizumab, Etanercept, Infliximab, Rituximab and Tocilizumab in a Real World Routine Care Registry [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10).