Two equally effective TNF inhibitors in rheumatoid arthritis

Adalimumab and etanercept are equally effective as tumor necrosis factor (TNF) inhibitors in the treatment of patients with active rheumatoid arthritis (RA), report researchers.

"We have shown, in the first head-to-head randomized comparison of two TNF inhibitors for the treatment of RA in a study designed to reflect real clinical practice, that adalimumab is not inferior to etanercept in terms of persistence with therapy over 2 years," say Paresh Jobanputra (Queen Elizabeth Hospital, Birmingham, UK) and colleagues.

The choice of first TNF inhibitor is an important milestone in the treatment pathway of a patient with RA, says the team. In the absence of trials comparing these agents, the team tested the effects of adalimumab 40 mg administered on alternate weeks and weekly etanercept 50 mg in a randomized, noninferiority trial, focusing on persistence of therapy as the primary outcome.

"Drug cessation, or continued use, are key indicators of successful therapy in chronic disease, especially where the prospect of drug free remission is low and drug costs are high," note Jobanputra et al.

The team decided that a difference in continuation rates of 15% between etanercept and adalimumab was clinically important and would be sufficient for clinicians to choose one agent over another.

As reported in BMJ Open, among 120 patients who had active RA despite treatment with two disease-modifying drugs (DMARDs), 39 (65%) of 60 patients who started adalimumab were still taking the drug at 52 weeks compared with 34 (57%) of 60 who were taking etanercept. After 104 weeks, 35 (58%) of 60 were still taking adalimumab and 26 (43%) of 60 were still taking etanercept.

The proportion of good, moderate, and nonresponders at 52 weeks, based on disease activity score using 28 joints, were similar in the groups, at 26.3%, 33.3%, and 40.4%, respectively, with adalimumab, compared with 16.7%, 31.7%, and 51.7%, respectively, for etanercept.

Fourteen serious adverse events occurred in 13 patients, six of whom were from the adalimumab group and seven from the etanercept group.

"Clinicians needing to choose between adalimumab and etanercept, in a patient with active RA despite treatment with methotrexate and another DMARD, may choose either agent in the knowledge that continuation or persistence with therapy 2 years is likely to be similar for these two agents," concludes the team.

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