Analysis Finds Tocilizumab Superior to Conventional DMARDs in RA

A comparative effectiveness analysis of biologics for rheumatoid arthritis (RA) showed that tocilizumab monotherapy and tocilizumab plus methotrexate were superior to conventional disease-modifying antirheumatic drugs (cDMARDs) alone and to standard care and as effective as other biologics in RA, reported researchers in Clinical Rheumatology.
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Because of the multiple biologic DMARDs available for the treatment of RA and the limited number of head-to-head comparisons of these treatments, Rafael Alfonso-Cristancho, MD, MSc, PhD, University of Washington (Seattle, WA), and colleagues conducted a systematic review and network meta-analysis to compare treatment strategies that incorporate biologics and cDMARDs. The systematic review used randomized controlled trials (RCTs) in adults with RA who failed treatment with cDMARDs.

The researchers compared the effectiveness of abatacept, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, and rituximab to tocilizumab, which was chosen as the reference biologic because of its different mechanism of action (anti-IL-6 receptor). For cDMARDs, only methotrexate at the recommended dose was included in the analysis. A total of 207 articles were included, describing 68 RCTs that were used for the network meta-analysis. The analysis included four outcomes: American College of Rheumatology ACR20, ACR 50, ACR 70, and European League Against Rheumatism (ELUAR) score; two time points: 26 and 52 weeks; and 3 levels of aggregation for pooling different doses of interventions.

Overall, the researchers found inconsistency and varying degrees of methodological quality in the systematic review of RCTs. The network meta-analysis showed tocilizumab alone was superior to standard care in achieving ACR20, ACR50, ACR70, and EULAR response at 26 weeks of follow-up. Tocilizumab monotherapy was also significantly better than methotrexate monotherapy for achieving ACR 50, ACR 70, and EULAR response at 26 weeks of follow-up. Similarly, the combination of tocilizumab plus methotrexate was significantly better than standard care and methotrexate alone for ACR20, ACR50, ACR70, and EULAR response at 26 weeks of follow-up.

At 52 weeks, when compared with methotrexate alone, tocilizumab plus methotrexate were significantly better for ACR20 and ACR50 response. However, no comparison was possible with standard care at 52 weeks due to lack of data. Few significant differences were found between tocilizumab (alone or in combination) and any other biologics.

As new evidence and agents become available, the investigators said that additional analysis is warranted to improve the quality of these comparisons. —Eileen Koutnik-Fotopoulos


Alfonso-Cristancho R, Armstrong N, Arjunji R, et al. Comparative effectiveness of biologics for the management of rheumatoid arthritis: systematic review and network meta-analysis [published online October 10, 2016]. Clin Rheumatol. doi:10.1007/s10067-016-3435-2.