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Immune Effects of Etanercept and Infliximab May Differ in Patients With Rheumatoid Arthritis

Patients with rheumatoid arthritis who do not respond fully to etanercept, a tumour necrosis factor inhibitor, may experience improved disease control with a switch to infliximab, another tumour necrosis factor inhibitor, according to a new study.

In this small retrospective study, Karen E. Hansen, MD, Veterans Hospital, Madison, Wisconsin, United States, and colleagues compared the response of 20 patients with rheumatoid arthritis (RA) who switched from etanercept to infliximab (switchers) with that of 73 patients with RA receiving infliximab with no prior TNF therapy (controls).

Of the 20 patients who switched to infliximab, 17 discontinued etanercept due to lack of efficacy, 1 stopped etanercept due to a shortage of the drug, and another stopped due to patient concern about safety of the drug.

Efficacy measures included tender and swollen joint counts, morning stiffness, dose of prednisone, sedimentation rate, and C-reactive protein (CRP). Global subjective assessments obtained from physicians and patients were recorded.

After onset of infliximab therapy, both groups experienced a clinically significant improvement in disease measures including tender and swollen joint counts, patient and physician global subjective assessment, CRP and morning stiffness.

These disease measures improved in a similar fashion in the switcher and control group with no significant difference being observed between the two. The reduction in prednisone dose was also similar between the groups.

Safety measures, included blood count, liver enzymes, albumin, and creatinine, before taking etanercept and after the switch to infliximab therapy. Number and severity of infusion reactions, infections, hospitalisation, other side effects, and death were recorded.

There was no evidence of haematological or hepatic toxicity in either group of patients. Three infections occurred in the switcher group and 7 infections in the control group (15% and 9.6%, respectively; P = .69 for the difference between the groups).

"From this study and our own experience, we infer that lack of efficacy to one anti-TNF agent does not predict lack of response to another TNF inhibitor," write the authors.

"A better understanding of this concept may prove valuable, as 3 anti-TNF therapies are commercially available for treatment of rheumatoid arthritis (RA). Research is needed to define the patients characteristics that predict a response to different TNF inhibitors, such as pharmacokinetics, TNF polymorphisms, cytokine profiles, and disease measures," the authors conclude.

J Rheumatol 2004 Jun;31:6:1098-102 "The efficacy of switching from etanercept to infliximab in patients with rheumatoid arthritis"

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