Meta-analysis of Clinical and Radiological Efficacy of Biologics in Rheumatoid Arthritis Patients Naive or Inadequately Responsive to Methotrexate

Our aim was to compare all eight biologics available for rheumatoid arthritis in two patient populations, methotrexate-naive patients and inadequate responders to methotrexate, based on a comprehensive literature review. The five TNFα antagonists, rituximab, abatacept and tocilizumab used with methotrexate were compared to methotrexate monotherapy using the ACR50 response as the primary clinical endpoint and absence of radiographic progression after 1 year as the primary radiological endpoint. Odds ratios (ORs) were computed, as well as the number needed to treat (NNT) to obtain an ACR50 response for each biologic. We included 22 studies. Overall, combined biologic therapy was significantly more effective than methotrexate alone in both the naive group (OR: 2.11; 95% confidence interval [95%CI], 1.85-2.41) and the unresponsive group (OR: 4.82; 95%CI: 3.83, 6.08). Crude NNTs were as follows: etanercept, five in the naive group and three in the unresponsive group; adalimumab, seven and three; infliximab, seven and five; abatacept, seven and four; rituximab, five and five; and tocilizumab and certolizumab, four in the unresponsive group. None of the differences was statistically significant. In the naive group, combined biologic therapy was associated with a higher rate of absence of radiographic progression after 1 year compared to methotrexate alone (OR: 2.19; 95%CI: 1.55-3.08). All biologics had approximately the same efficacy. Methotrexate-naive patients treated with biologics had significantly less radiographic progression than those with cellular therapy.