title: The comparative efficacy and safety of biologics for the treatment of rheumatoid arthritis: a systematic review and metaanalysis.
abstract: OBJECTIVE
  Biologics are an important therapeutic option for treating patients with rheumatoid arthritis (RA). However, they are associated with rare but severe adverse events such as serious infections, lymphoma, or chronic heart failure. In addition, dosing regimens and routes of administration differ substantially among biologics. In a systematic review, we assessed the comparative efficacy and safety of biologic agents for RA.
  
  
  METHODS
  We searched electronic databases up to May 2006. We limited evidence to controlled trials for efficacy but included observational evidence for safety. Outcomes of interest were clinical response, radiographic progression, and quality of life. Given the paucity of head-to-head evidence, we conducted adjusted, indirect comparisons of placebo-controlled trials.
  
  
  RESULTS
  Twenty-six controlled trials provided efficacy data; 18 additional studies assessed safety. The only evidence directly comparing 2 biologic agents was a nonrandomized, open-label trial that found no differences in effectiveness and safety between etanercept and infliximab. Adjusted indirect comparisons indicate no significant differences in efficacy between anti-tumor necrosis factor (TNF) drugs. However, anti-TNF drugs appear to be more efficacious than anakinra, although not all comparisons reached statistical significance. Because of the lack of sound longterm safety data, evidence is insufficient to draw firm conclusions about the comparative safety of biologics.
  
  
  CONCLUSIONS
  Anti-TNF drugs appear to be more efficacious than anakinra but do not differ significantly among each other. Clinical considerations such as comorbidities, route of administration, dosing regimens, and specific side effect profiles may guide the choice of an anti-TNF drug.
authors.affiliation: Cecil G. Sheps Center for Health Services, and School of Public Health, Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA. gartlehner@schsr.unc.edu
authors.forename: Gerald
authors.initials: G
authors.lastname: Gartlehner
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hansen
authors.forename: Beth L
authors.initials: BL
authors.lastname: Jonas
authors.forename: Patricia
authors.initials: P
authors.lastname: Thieda
authors.forename: Kathleen N
authors.initials: KN
authors.lastname: Lohr
mesh_terms: D018501:Antirheumatic Agents / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy*; D001688:Biological Products / Q000009:adverse effects*; D018849:Controlled Clinical Trials as Topic; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors / Q000276:immunology
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha