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Risks and Benefits of Tumor Necrosis Factor-α Inhibitors in the Management of Psoriatic Arthritis: Systematic Review and Metaanalysis of Randomized Controlled Trials
AMR A. SAAD, DEBORAH P.M. SYMMONS, PETER R. NOYCE, and DARREN M. ASHCROFT
ABSTRACT. Methods. We searched electronic databases to identify randomized controlled trials (RCT) of adalimumab, etanercept, and infliximab used in patients with PsA. Random effects metaanalysis was undertaken to produce pooled estimates of the relative risk, risk difference, or the weighted mean difference for efficacy and safety outcomes using Stata version 9.0. Results. Six RCT met the inclusion criteria, including 982 patients. All 3 TNF-a inhibitors were significantly more effective than placebo on the basis of Psoriatic Arthritis Response Criteria (PsARC) and American College of Rheumatology response criteria ACR20, ACR50, and ACR70 ratings. There were no significant differences between TNF-a inhibitors and placebo in the proportions of patients experiencing withdrawal for any reason (RR 0.48, 95% CI 0.20-1.18), or withdrawal due to adverse events (RR 2.14, 95% CI 0.73-6.27), serious adverse events (RR 0.98, 95% CI 0.55-1.77), or upper respiratory tract infections (RR 0.91, 95% CI 0.65-1.28). Pooled rates for injection site reactions were significantly higher for adalimumab and etanercept than for placebo (RR 2.48, 95% CI 1.16-5.29), but there was no significant difference in the proportion of patients experiencing infusion reactions with infliximab (RR 1.03, 95% CI 0.48-2.20) compared against placebo. Indirect analysis did not demonstrate any significant differences between the TNF-a inhibitors. Conclusion. TNF-a inhibitors are effective treatments for PsA with no important added risks associated with their short-term use. There is still a need for longterm risk-benefit assessment of using these drugs for the management of PsA. (J Rheumatol First Release Mar 15 2008) Key Indexing Terms:
PSORIATIC ARTHRITIS
From the School of Pharmacy and Pharmaceutical Sciences, and Arthritis Research Campaign (ARC) Epidemiology Unit, University of Manchester, Manchester, UK. Mr. Saad acknowledges support of the Egyptian Government for funding his PhD studentship at The University of Manchester. A.A. Saad, MSc, PhD Student, School of Pharmacy and Pharmaceutical Sciences; D.P.M. Symmons, MD, Professor of Rheumatology, Arthritis Research Campaign (ARC) Epidemiology Unit; P.R. Noyce, PhD, Professor of Pharmacy Practice; D.M. Ashcroft, PhD, Reader in Medicines Usage and Safety, School of Pharmacy and Pharmaceutical Sciences, University of Manchester. Address reprint requests to Dr. D. Ashcroft, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK. E-mail: darren.ashcroft@manchester.ac.uk Accepted for publication December 22, 2007. |
