TNF-α Inhibitors Prove their Worth in PsA

Tumor necrosis factor-a (TNF-α) inhibitors are effective in treating a number of inflammatory arthritides¹  – and psoriatic arthritis (PsA) proves no exception.

In April, we reported the longest-available clinical trial data for any TNF-α drug, showing that golimumab (Simponi) produced significant improvements in joint pain, swelling, and psoriatic skin lesions in a majority of PsA patients over five years.²

Now a meta-analysis by authors from Brazil, just published online in Rheumatology International,, reached the conclusion that most TNF-blockers produce similar results.³

The systematic review found that after just six months of treatment, more PsA patients taking TNF-α drugs than controls had 20%, 50%, and 70% responses according to American College of Rheumatology criteria (ACR20, ACR50, and ACR70) in clinical trials.³

Patients who used golimumab, adalimumab (Humira) and etanercept (Enbrel) were more likely to achieve ACR20 and ACR50 responses after 12 to 24 weeks of treatment compared with controls/placebo, according to the meta-analysis.³ It contempated nine randomized controlled trials (RCTs) and six observational studies of golimumab, adalimumab, etanercept, and/or infliximab (Enbrel) -- either compared with placebo or with each other -- in adults with PsA and/or psoriasis.

Analyzing data from all patients originally randomized to TNF-α inhibitors or placebo in RCTs for at least six months, it also found that the former had better results judging by the Psoriatic Arthritis Response Criteria (PsARC) and the Psoriasis Area and Severity Index (PASI75).² And these patients more often reached radiographic end points (including Sharp/van der Heijde scores) than did controls, with time-dependent results: The longer patients used the drugs, the better their X-ray results.³

The five-year results from the GO-REVEAL trial of golimumab, published in the Annals of the Rheumatic Diseases last month, revealed sustained ACR20 responses in up to 70% of PsA patients and ACR50 responses in more than half of patients, as well as slowing of radiographic progression in over 70% of patients with or without concomitant methotrexate (MTX).⁴

PsA is a spondyloarthritis (SpA) that affects 30% of people with psoriasis, and is also associated with ankylosing spondylitis (AS).³ PsA and AS produce peripheral or axial arthritis and stiffness involving tendons and ligaments, which eads to a decreased ability to perform daily activities and reduced quality of life.

Other manifestations of this family of inflammatory spondyloarthritides include sacroiliitis with inflammatory back pain, peripheral joint pain, enthesitis, dactylitis and extra-articular manifestations including uveitis and inflammatory bowel disease (IBD), as well as psoriasis.³

For patients with other SpAs, non-steroidal anti-inflammatory drugs (NSAIDs) are used to relieve musculoskeletal signs and symptoms, while synthetic disease-modifying anti-rheumatic drugs (DMARDs) are used to reduce inflammation and disease progression.³

However, DMARDs produce only limited results. TNF-α drugs are used in AS and other SpAs only when DMARDs fail or in patients with predominantly axial involvement or severe enthesitis.¹

The main goal of the treatment in PsA, AS, and other members of this disease family, is to maximize long-term health-related quality of life, through symptom control, prevention of structural damage, and normalization of function.

In PsA, the meta-analysis showed function, fatigue and quality of life improved in patients using anti-TNF drugs after 12 to 24 weeks.³

While the Brazilian review found no apparent differences in overall efficacy and effectiveness among the anti-TNF drugs, the authors raise the obvious point that defining superiority would require head-to-head studies.

A recent review in the International Journal of Immunopathology and Pharmacology of the TNF-α inhibitors approved for these and other immune-mediated inflammatory diseases (IMIDs) deemed the evidence best overall for adalimumab.¹ It concludes that adalimumab shows efficacy and tolerability for the widest range of indications in controlled controlled clinical trials, as well as in long-term data from observational studies, confirming it as a “suitable choice” in the management of IMIDs.¹

However, only the abstract of this publication in a journal supplement is available online, and author conflicts (if any) are not declared.

References:

1.  Armuzzi A, Lionetti P, Blandizzi C, et al., Anti-TNF agents as therapeutic choice in immune-mediated inflammatory diseases: focus on adalimumab. Int J Immunopathol Pharmacol. (2014) Jan-Mar;27(1 Suppl):11-32.  (Full text not available online.)

2.  Baron-Faust, R. Golimumab Gives Long-Term Improvement in PsA. Rheumatology Network, April 25, 2014.

3.  Lemos LL, de Oliveira Costa J, Almeida AM, et al.,Treatment of psoriatic arthritis with anti-TNF agents: a systematic review and meta-analysis of efficacy, effectiveness and safety.Rheumatol Int. (2014) Apr 13. [Epub ahead of print March 2014]

4.  Kavanaugh A, McInnes IB, Mease P, et al. Clinical efficacy, radiographic and safety findings through 5 years of subcutaneous golimumab treatment in patients with active psoriatic arthritis: results from a long-term extension of a randomised, placebo-controlled trial, the GO-REVEAL study). Ann Rheum Dis. (2014) [Online First: April 19, 2014] doi:10.1136/annrheumdis-2013-204902