title: Comparative efficacy of biological agents in methotrexate-refractory rheumatoid arthritis patients: a Bayesian mixed treatment comparison.
abstract: OBJECTIVE
  Biological agents (biologics) targeting proinflammatory signaling have emerged as an important treatment option in rheumatoid arthritis (RA). Despite the clinical effectiveness of biologics for patients with RA who do not respond to 'traditional' disease-modifying anti-rheumatic drugs (DMARDs), there are concerns regarding their cost and long-term safety. In this study, we aimed to compare the efficacy of various biologics and traditional DMARDs in RA patients refractory to methotrexate (MTX).
  
  
  METHODS
  Four DMARDs (hydroxychloroquine, sulfasalazine, MTX, lef lunomide) and five anti-tumor necrosis factor drugs (adalimumab, etanercept, golimumab, inf liximab, and certolizumab) were selected. A systematic search of published studies was performed from inception through July 2013. Randomized trials of adults with MTX-refractory RA comparing two or more of the selected medications were included. Among 7,938 titles identified, in total, 16 head-to-head trials were selected. Two reviewers independently abstracted the study data and assessed methodological quality using the Cochrane Risk of Bias. Comparative efficacy was analyzed using a Bayesian mixed treatment comparison (MTC).
  
  
  RESULTS
  In total, 9, 4, and 11 studies were included for the outcome measures of the Health Assessment Questionnaire (HAQ), Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) < 2.6 (remission), and American College of Rheumatology (ACR) 70 response, respectively. The treatments with the highest efficacy for each outcome measure were certolizumab combined with MTX, golimumab combined with MTX, and certolizumab combined with MTX, respectively.
  
  
  CONCLUSIONS
  Based on MTC analysis, using data from published randomized controlled trials, certolizumab and golimumab combined with MTX showed the highest efficacy in the three outcome measures (HAQ, DAS28-ESR < 2.6, and ACR 70 response) in MTX-refractory RA patients.
authors.affiliation: National Evidence-Based Healthcare Collaboration Agency (NECA), Seoul, Korea.
authors.forename: Miyoung
authors.initials: M
authors.lastname: Choi
authors.affiliation: Department of Preventive Medicine, Dongguk University College of Korean Medicine, Seoul, Korea.
authors.forename: Min Kyung
authors.initials: MK
authors.lastname: Hyun
authors.affiliation: Korea Appraisal Board, Real Estate R&D Institute, Seoul, Korea.
authors.forename: Seongmi
authors.initials: S
authors.lastname: Choi
authors.affiliation: National Evidence-Based Healthcare Collaboration Agency (NECA), Seoul, Korea.
authors.forename: Ha Jin
authors.initials: HJ
authors.lastname: Tchoe
authors.affiliation: Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea.
authors.forename: Sung Yeon
authors.initials: SY
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea.
authors.forename: Kyeong Min
authors.initials: KM
authors.lastname: Son
authors.affiliation: National Evidence-Based Healthcare Collaboration Agency (NECA), Seoul, Korea.
authors.forename: Min-Jeong
authors.initials: MJ
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea.
authors.forename: Young Ok
authors.initials: YO
authors.lastname: Jung
authors.affiliation: Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea.
authors.forename: Hyun Ah
authors.initials: HA
authors.lastname: Kim
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001499:Bayes Theorem; D006801:Humans; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents
keywords: Antirheumatic agents; Arthritis, rheumatoid; Biological products; Mixed treatment comparison