Majority of Rheumatoid Arthritis Patients Qualifying for Therapy With Tumour Necrosis Factor Alpha Blocking Agents May Respond to Escalation of Conventional Therapy

[Guest guest]

Majority of Rheumatoid Arthritis Patients Qualifying for Therapy With Tumour

Necrosis Factor Alpha Blocking Agents May Respond to Escalation of

Conventional Therapy

A DGReview of : " The impact of escalating conventional therapy in rheumatoid

arthritis patients referred for anti-tumour necrosis factor-{alpha} therapy "

Rheumatology

12/22/2003

By Jill

More than half of patients with rheumatoid arthritis (RA) who satisfied

guidelines for treatment with tumour necrosis factor-alpha (TNF alpha)

blocking agents responded satisfactorily to escalated conventional therapy

for at least 1 year, according to a British study.

TNF alpha blocking agents, such as etanercept and infliximab, are highly

effective in reducing RA disease activity. However, due to drug expense and

uncertainties regarding long-term toxicity, biologics are reserved for

patients with persistent active disease failing to respond to conventional

therapy with disease-modifying anti-rheumatic drugs (DMARDs).

Recently, the British Society for Rheumatology (BSR) published guidelines

for appropriate selection of patients for anti-TNF alpha therapy, which have

been adopted by The National Institute of Clinical Excellence (NICE).

To assess if RA patients qualify for anti-TNF alpha therapy according to

BSR/NICE guidelines, S. J. Bingham of Leeds General Infirmary, Leeds, United

Kingdom, and colleagues conducted a prospective study in 308 consecutive

patients considered to have failed conventional therapy.

Prior to starting treatment with biologics, patients were treated according

to a protocol of intensified conventional therapy escalating from

sulphasalazine or methotrexate monotherapy to a combination of methotrexate

and/or sulphasalazine and/or hydroxychloroquine, to parenteral methotrexate,

and finally to leflunomide.

Patient assessment occurred at 12-weekly intervals for 1 year, after which

therapy was altered in cases of unsatisfactory response. For analysis, the

BSR/NICE biologic eligibility criteria were applied retrospectively, and

response to escalated therapy in patients who did or did not satisfy

BSR/NICE criteria were compared.

Results revealed that 159 patients satisfied BSR/NICE criteria and would

have been eligible for immediate treatment with biologics. However, 93 of

these patients showed significant improvement in disease activity,

disability, and quality of life as a result of escalated conventional

therapy and did not require biologics.

A moderate or good response (as defined by European League Against

Rheumatism criteria) was achieved with escalated conventional therapy in 32%

of patients at 6 months and 55% of patients at 12 months. However, only 7%

of patients achieved a mild disease activity score (DAS28<3.2) at 12 months.

" The simplistic interpretation of this result is that not all patients

fulfilling BSR/NICE guidelines require anti-TNF alpha therapy, " the

researchers conclude. " The aim of the guidelines is to restrict biologics to

those patients who have no alternatives, but this study suggests that

patients should be required to have failed escalated therapy in order to

qualify. "

Rheumatology (Oxford) 2003 Dec 1