title: Risks and benefits of tumor necrosis factor-alpha inhibitors in the management of psoriatic arthritis: systematic review and metaanalysis of randomized controlled trials.
abstract: OBJECTIVE
  To evaluate the efficacy and safety of tumor necrosis factor-alpha (TNF-alpha) inhibitors in the management of psoriatic arthritis (PsA).
  
  
  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-alpha 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-alpha 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-alpha inhibitors.
  
  
  CONCLUSIONS
  TNF-alpha 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.
authors.affiliation: School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK.
authors.forename: Amr A
authors.initials: AA
authors.lastname: Saad
authors.forename: Deborah P M
authors.initials: DP
authors.lastname: Symmons
authors.forename: Peter R
authors.initials: PR
authors.lastname: Noyce
authors.forename: Darren M
authors.initials: DM
authors.lastname: Ashcroft
mesh_terms: D000068879:Adalimumab; D000328:Adult; D000911:Antibodies, Monoclonal / Q000009:adverse effects / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D015535:Arthritis, Psoriatic / Q000188:drug therapy*; D000068800:Etanercept; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000009:adverse effects / Q000627:therapeutic use; D000069285:Infliximab; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D018124:Receptors, Tumor Necrosis Factor / Q000627:therapeutic use; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab; D000068800:Etanercept