Rheumatology Department, Lapeyronie University Hospital, Montpellier I University, Montpellier, France.
Clin Exp Rheumatol. 2011 Jan-Feb;29(1):96-103. Epub 2011 Feb 23.
To assess the clinical relevance of switching to a second tumour necrosis factor (TNF) alpha inhibitor after discontinuation of a first TNF-alpha inhibitor in patients with rheumatoid arthritis.
A systematic literature search of MEDLINE, EMBASE and Cochrane database and Congress abstracts up to March 2009 retrieved all studies assessing the efficacy of switching to a second TNF-alpha inhibitor. Key words were rheumatoid arthritis AND failure OR switching AND TNF-alpha inhibitors OR adalimumab OR etanercept OR infliximab. Efficacy was evaluated by American College of Rheumatology (ACR), European League Against Rheumatism (EULAR) response criteria and drug survival. A meta-analysis of the percentage of responders was carried out. Statistical heterogeneity was tested by the Q-test.
In the 32 relevant studies (4,441 patients) selected, the pooled percentage of ACR 20 responders (12 studies; 1,570 patients) was 55.1% (95% confidence interval, CI 48.2-62) and that of EULAR responders (15 studies; 2,665 patients) was 74.9% (95% CI 72.3-77.5). In the 19 studies analysing the efficacy by the reason to switch, the pooled percentage of ACR20 responders was 54.3% (95% CI 45.8-62.5) for switch because of lack of efficacy and 62.5% (95% CI 57.3-67.6) because of adverse events. The percentage of EULAR response was similar in both groups.
This meta-analysis suggests that switching to a second TNF-alpha inhibitor is clinically relevant in RA. Response to a second TNF-alpha inhibitor appears to be slightly better if the first TNF-alpha inhibitor was discontinued because of adverse events.
评估类风湿关节炎患者停用首支肿瘤坏死因子（TNF）α抑制剂后换用第二支 TNFα抑制剂的临床相关性。
对 MEDLINE、EMBASE 和 Cochrane 数据库以及截至 2009 年 3 月的会议摘要进行系统文献检索，检索所有评估换用第二支 TNFα抑制剂疗效的研究。关键词为类风湿关节炎和失败或转换和 TNFα抑制剂或阿达木单抗或依那西普或英夫利昔单抗。通过美国风湿病学会（ACR）、欧洲抗风湿病联盟（EULAR）反应标准和药物生存评估疗效。对反应者的百分比进行了荟萃分析。通过 Q 检验测试了统计异质性。
在纳入的 32 项相关研究（4441 例患者）中，ACR20 反应者的汇总百分比（12 项研究；1570 例患者）为 55.1%（95%置信区间，48.2-62），EULAR 反应者的汇总百分比为 74.9%（95%置信区间，72.3-77.5）。在分析因转换原因而疗效的 19 项研究中，因缺乏疗效而换用的 ACR20 反应者的汇总百分比为 54.3%（95%置信区间，45.8-62.5），因不良反应而换用的为 62.5%（95%置信区间，57.3-67.6）。两组的 EULAR 反应率相似。
本荟萃分析表明，换用第二支 TNFα抑制剂对 RA 具有临床相关性。如果因不良反应而停用首支 TNFα抑制剂，换用第二支 TNFα抑制剂的反应似乎略好。
