Difficult-to-treat RA (D2T-RA) is defined as persistent disease activity or progression despite the use of two different DMARDs with different modes of action, such as biologics. Several different drugs can be used in such cases and have shown good efficacy in studies. However, a comparison of these different substances has been lacking until now. A recent meta-analysis has addressed this issue and examined how the various substances perform.
In the meta-analysis, tocilizumab performed best. Compared to the other drugs, it improved the DAS28 score the most and ranked second for the ACR50 score.
The IL-6 inhibitor works best at higher doses, so an 8 mg dose every 4 weeks is preferable. To reduce the likelihood of adverse effects, strict patient selection should be performed and the drug should not be prescribed if there are contraindications, such as severe infections or tuberculosis. Tocilizumab can be combined with methotrexate to improve tolerability.
The monoclonal antibody sarilumab came in second in the study. It is effective with a favourable risk profile and fewer adverse effects than other drugs in the analysis. The target dose for sarilumab is 200 mg every two weeks.
The study rated rituximab as the safest overall. In addition, 4 mg per day of baricitinib showed good efficacy. Olokizumab achieved the greatest overall change in ACR50 scores, but had a higher level of adverse effects.
While the study provides an interesting comparison of the advantages and disadvantages of various treatment options for difficult-to-treat RA, the results should not be accepted uncritically. Overall, the meta-analysis was a small study with a small sample size. The authors themselves describe the presence of bias. The results can provide good guidance when deciding for or against certain medications, but should not be taken as absolute facts.