Thorlund Kristian, Druyts Eric, Aviña-Zubieta J Antonio, Mills Edward J
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
Biologics. 2012;6:417-27. doi: 10.2147/BTT.S37606. Epub 2012 Dec 3.
To evaluate the comparative effectiveness of available tumor necrosis factor-α inhibitors (anti-TNFs) for the management of psoriatic arthritis (PsA) in patients with an inadequate response to disease-modifying antirheumatic drugs (DMARDs).
We used an exhaustive search strategy covering randomized clinical trials, systematic reviews and health technology assessments (HTA) published on anti-TNFs for PsA. We performed indirect comparisons of the available anti-TNFs (adalimumab, etanercept, golimumab, and infliximab) measuring relative risks (RR) for the psoriatic arthritis response criteria (PsARC), mean differences (MDs) for improvements from baseline for the Health Assessment Questionnaire (HAQ) by PsARC responders and non-responders, and MD for the improvements from baseline for the psoriasis area and severity index (PASI). When the reporting of data on intervention group response rates and improvements were incomplete, we used straightforward conversions based on the available data.
We retrieved data from 20 publications representing seven trials, as well as two HTAs. All anti-TNFs were significantly better than control, but the indirect comparison did not reveal any statistically significant difference between the anti-TNFs. For PsARC response, golimumab yielded the highest RR and etanercept the second highest; adalimumab and infliximab both yielded notably smaller RRs. For HAQ improvement, etanercept and infliximab yielded the largest MD among PsARC responders. For PsARC nonresponders, etanercept, infliximab, and golimumab yielded similar MDs, and adalimumab a notably lower MD. For PASI improvement, infliximab yielded the largest MD and golimumab the second largest, while etanercept yielded the smallest MD. In some instances, the estimated magnitudes of effect were notably different from the estimates of previous HTA indirect comparisons.
There is insufficient statistical evidence to demonstrate differences in effectiveness between available anti-TNFs for PsA. Effect estimates seem sensitive to the analytic approach, and this uncertainty should be taken into account in future economic evaluations.
评估现有肿瘤坏死因子-α抑制剂（抗TNFs）在对改善病情抗风湿药（DMARDs）反应不足的银屑病关节炎（PsA）患者中治疗PsA的相对疗效。
我们采用全面的检索策略，涵盖已发表的关于抗TNFs治疗PsA的随机临床试验、系统评价和卫生技术评估（HTA）。我们对现有抗TNFs（阿达木单抗、依那西普、戈利木单抗和英夫利昔单抗）进行间接比较，测量银屑病关节炎反应标准（PsARC）的相对风险（RR）、PsARC反应者和非反应者的健康评估问卷（HAQ）相对于基线改善的平均差（MD），以及银屑病面积和严重程度指数（PASI）相对于基线改善的MD。当干预组反应率和改善情况的数据报告不完整时，我们根据现有数据进行直接转换。
我们从代表七项试验的20篇出版物以及两项HTA中检索到数据。所有抗TNFs均显著优于对照组，但间接比较未显示抗TNFs之间存在任何统计学上的显著差异。对于PsARC反应，戈利木单抗的RR最高，依那西普次之；阿达木单抗和英夫利昔单抗的RR均明显较小。对于HAQ改善，依那西普和英夫利昔单抗在PsARC反应者中产生的MD最大。对于PsARC无反应者，依那西普、英夫利昔单抗和戈利木单抗产生的MD相似，而阿达木单抗产生的MD明显较低。对于PASI改善，英夫利昔单抗产生的MD最大，戈利木单抗次之，而依那西普产生的MD最小。在某些情况下，效应估计值与先前HTA间接比较的估计值明显不同。
没有足够的统计证据证明现有抗TNFs治疗PsA的有效性存在差异。效应估计似乎对分析方法敏感，这种不确定性应在未来的经济评估中予以考虑。
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