The Crowded Market of RA Therapies: From Network Meta-Analyses to New Kids on the Block

• A new network meta-analysis shows that (not surprisingly), one or more drugs with background methotrexate are better than MTX alone! (abstract #1041). This was presented by Glen Hazlewood who had a record number of 3 oral presentations in one session! Makes me proud to be Canadian.

• Baricitinib 2 mg qd looks similar to 4 mg qd after one or more TNFi's and after >3 biologics. The response is blunted compared to not having previous treatment failures (as is true in ALL post-TNFi studies), and 4 mg may look better earlier but 2 mg daily catches up by 24 weeks. In ERA, baricitinib was superior to MTX as monotherapy and there seemed to be no obvious added benefit in ACR responses combining MTX + baricitinib vs baricitinib alone (abstracts #1046 and 1045).

• Sarilumab (IL-6 monoclonal Ab) SC responses look very similar to tocilizumab responses in TNFi inadequate responders in a placebo-controlled trial (abstract #970). The safety of TCZ and sarilumab was compared in a head-to-head study by Paul Emery and looked similar. (abstract #971).

• The dual TNFi and IL-17 inhibitor, ABT-122, appears to be safe in a Phase II trial. There are no efficacy data yet in Phase II but the word on the street is that this is heading for (or into) Phase III (abstract #967).

• It is difficult to know how long a patient is on rituximab due to variable dose intervals and outliers who don't need retreatment for long periods of time. The durability of rituximab in RA from the British Biologic Register (in ~1600 RA patients) was approximately 50% at 4 years. RA patients were more likely to be on rituximab for longer if rituximab was after their 1^st TNFi vs if it was further-line therapy (abstract #1040).

• Namilumab (anti-GM-CSF) looks better than placebo (not sure yet by how much) but will go into Phase III trials (abstract #969).

IMPLICATIONS for practice:

• More drugs are usually better than MTX (but seemingly not with baricitinib in MTX-unexposed ERA patients – but that is not how we treat new patients in clinical practice).

• You have to learn a lot of new names of drugs and how to pronounce them.

• Start unbooking your weekends as there will be several ad boards to go to.

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