title: Indirect comparisons of the efficacy of biological agents in patients with psoriatic arthritis with an inadequate response to traditional disease-modifying anti-rheumatic drugs or to non-steroidal anti-inflammatory drugs: A meta-analysis.
abstract: BACKGROUND
  While the efficacy of biologic agents for the treatment of psoriatic arthritis (PsA) has been well demonstrated in randomized controlled trials (RCTs), the data on their relative efficacy is limited. This meta-analysis is aimed at assessing the comparative efficacy of these agents in patients who had persistently active disease despite traditional non-steroidal anti-inflammatory drugs (NSAIDs)/disease-modifying anti-rheumatic drugs (DMARDs), or who could not tolerate NSAIDs/DMARDs.
  
  
  METHODS
  RCTs examining the efficacy of biologic agents in patients with PsA who experienced inadequate response or intolerance of traditional DMARDs or NSAIDs were identified. If more than one RCT were available for a given biologic agent, the pooled risk ratio (RR) and 95% confidence interval (CI) of attaining a 20% improvement according to American College of Rheumatology criteria (ACR20) response across trials were calculated. The pooled risk ratios for each biologic agent were then compared using the indirect comparison technique.
  
  
  RESULTS
  A total of 12 RCTs were identified and included in the data analyses. We found that patients who received older TNF inhibitors (etanercept, infliximab, adalimumab, and golimumab) had a statistically significantly higher chance of achieving ACR20 response compared with apremilast, ustekinumab, and certolizumab. The likelihood of achieving ACR20 response among secukinumab users (at the dose of 150 mg and 300 mg weekly) was also higher compared with apremilast, ustekinumab, and certolizumab, though the relative risk did not always reach statistical significance.
  
  
  CONCLUSIONS
  Our study demonstrates that patients with PsA who experience inadequate response or intolerance of traditional DMARDs or NSAIDs have a higher probability of achieving the ACR20 response with older TNF inhibitors and secukinumab.
authors.affiliation: Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Electronic address: P.Ungprasert@gmail.com.
authors.forename: Patompong
authors.initials: P
authors.lastname: Ungprasert
authors.affiliation: Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Charat
authors.initials: C
authors.lastname: Thongprayoon
authors.affiliation: Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
authors.forename: John M
authors.initials: JM
authors.lastname: Davis
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D015535:Arthritis, Psoriatic / Q000188:drug therapy*; D001688:Biological Products / Q000627:therapeutic use*; D006801:Humans; D019233:Retreatment; D016896:Treatment Outcome
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D018501:Antirheumatic Agents; D001688:Biological Products
keywords: Biologic agents; DMARDs; Meta-analysis; Psoriatic arthritis; Systematic review