title: Systematic review with network meta-analysis: the efficacy of anti-TNF agents for the treatment of Crohn's disease.
abstract: BACKGROUND
  Anti-tumour necrosis factor-alpha agents (anti-TNF) are effective therapies for the treatment of Crohn's disease (CD), but their comparative efficacy is unknown.
  
  
  OBJECTIVE
  To perform a network meta-analysis comparing the efficacy of anti-TNF therapies in CD.
  
  
  METHODS
  After screening 506 studies, reviewers extracted information on 10 studies. Traditional meta-analysis (TMA) was used to compare each anti-TNF agent to placebo. Bayesian network meta-analysis (NMA) was performed to compare the effects of anti-TNF agents to placebo. In addition, sample sizes for comparative efficacy trials were calculated.
  
  
  RESULTS
  Compared to placebo, TMA revealed that anti-TNF agents result in a higher likelihood of induction of remission and response (RR: 1.66, 95% CI: 1.17-2.36 and RR: 1.43, 95% CI: 1.17-1.73, respectively) as well as maintenance of remission and response (RR: 1.78, 95% CI: 1.51-2.09 and RR: 1.68, 95% CI: 1.46-1.93, respectively). NMA found nonsignificant trends between infliximab and adalimumab or certolizumab pegol. Among subcutaneous therapies, NMA demonstrated superiority of adalimumab to certolizumab pegol for induction of remission (RR: 2.93, 95% CrI: 1.21-7.75). Sample size calculations suggest that adequately powered head-to-head comparative efficacy trials would require greater than 3000 patients.
  
  
  CONCLUSIONS
  All anti-TNF agents are effective for induction and maintenance of response and remission in the treatment of CD. Although adalimumab is superior to certolizumab pegol for induction of remission, there is no evidence of clinical superiority among anti-TNF agents. Head-to-head trials among the anti-TNF agents are impractical in terms of size and cost.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
authors.forename: R W
authors.initials: RW
authors.lastname: Stidham
authors.forename: T C H
authors.initials: TC
authors.lastname: Lee
authors.forename: P D R
authors.initials: PD
authors.lastname: Higgins
authors.forename: A R
authors.initials: AR
authors.lastname: Deshpande
authors.forename: D A
authors.initials: DA
authors.lastname: Sussman
authors.forename: A G
authors.initials: AG
authors.lastname: Singal
authors.forename: B J
authors.initials: BJ
authors.lastname: Elmunzer
authors.forename: S D
authors.initials: SD
authors.lastname: Saini
authors.forename: S
authors.initials: S
authors.lastname: Vijan
authors.forename: A K
authors.initials: AK
authors.lastname: Waljee
mesh_terms: D000068879:Adalimumab; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D001499:Bayes Theorem; D000068582:Certolizumab Pegol; D003424:Crohn Disease / Q000188:drug therapy*; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use; D000069285:Infliximab; D011092:Polyethylene Glycols / Q000627:therapeutic use; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D007140:Immunoglobulin Fab Fragments; D014409:Tumor Necrosis Factor-alpha; D011092:Polyethylene Glycols; D000069285:Infliximab; D000068879:Adalimumab; D000068582:Certolizumab Pegol
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