Cochrane Reports Moderate Evidence Favoring Biologic Add-on Therapy Save

Singh and coworkers have assessed the value of adding a biologic to rheumatoid arthritis (RA) patients not responding to either methotrexate (MTX) or DMARDs. The results of their netowork metanalsysis is published as a Cochrane review wherein they examined a total of 90 RCTs (73 new) with 32,874 participants.

Overall, they found moderate evidence that adding a biologic to either MTX or a DMARD yielded significant and clinically meaningful improvement in ACR50 scores versus comparator (RR 2.71 (95% CI 2.36 to 3.10). The estimated ACR50 responses were similar between TNF biologics (RR 3.23), non-TNF biologics (RR 2.99) and anakinra (RR 2.37).  

They also showed that biologics were capable of significant benefit in functional outcomes (assessed by HAQ) and remission rates assessed by DAS scores (RR 2.81).

While there was evidence that radiographic progression was significantly reduced on biologics + MTX/DMARDs, the absolute reduction was small (-0.58%; 95% CI -0.91% to -0.25%) making the clinical relevance of this reduction less certain.

Safety analyses found inconclusive evidence that biologics + MTX/DMARDs are associated with an increased risk of cancer or more withdrawals due to adverse events.  

These 6-12 month randomized clinical trials provide further evidence favoring the addition of biologic therapy in patients not responding to MTX or DMARD therapy.