Elsevier

Joint Bone Spine

Volume 74, Issue 6, December 2007, Pages 523-526
Joint Bone Spine

Editorial
TNFα antagonists in rheumatoid arthritis patients seen in everyday practice

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Section snippets

Effectiveness of TNFα antagonist therapy

TNFα antagonist therapy was effective in numerous clinical trials in patients with recent-onset or established RA. Although no comparative studies have been published to date, the three currently available TNFα antagonists seem similar in terms of efficacy, with response rates of 55%–80% for ACR20, 45%–65% for ACR50, and 35%–40% for ACR70 [2], [3], [4]. The results are best when the TNFα antagonist is combined with another drug, chiefly methotrexate. Although 40% of patients can expect to

Reasons for TNFα antagonist therapy discontinuation

Lack of efficacy and side effects explain similar proportions of treatment discontinuation [17], about 10%–30% for each. The remaining third is ascribable to financial reasons and to personal preferences of patients and physicians. Among RA patients who were switched to a second TNFα antagonist for lack of efficacy or toxicity, the hazards ratio of discontinuing the second drug for the same reason as the first was about 2 [18]. On the other hand, etanercept continuation rates were higher in

Side effects

The risk of infection is increased about twofold in RA patients overall and increases further with TNFα antagonist therapy [20]. In clinical therapeutic trials, the risk of infection was slightly higher with anti-TNFα antibodies given in combination with methotrexate, with about 5–6.5 serious infections/patient-year. The main reason for combining methotrexate with TNFα antagonist therapy is that efficacy is greater with combination therapy. In observational cohorts, the risk increase was

Dosage adjustment and treatment continuation

An important question is whether TNFα antagonist therapy reduces glucocorticoid requirements and/or the overall cost of RA management. Study reports have supplied little information on a possible glucocorticoid-sparing effect. The methotrexate–etanercept combination may decrease glucocorticoid requirements, perhaps at the expense of greater NSAID use [28]. Decreasing the etanercept dosage may diminish the cost of treatment and reduce side effects. Overall, the cost of TNFα antagonist treatment

Future limitations

The high prevalence of infection with the hepatitis B and C viruses requires routine screening, as chronic carriers may be at risk for reactivation after the introduction of TNFα antagonist therapy [30]. Administration of an antiviral drug such as lamivudine may reduce the risk of reactivation. Other viral infections (e.g., herpes) may be increased and require specific surveillance.

In patients who want to become pregnant, TNFα antagonist therapy should be stopped, as proof of safety for the

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