Personalization of biologic therapy in patients with rheumatoid arthritis: less frequently accounted choice-driving variables
Received 30 May 2018
Accepted for publication 9 September 2018
Published 24 October 2018 Volume 2018:14 Pages 2097—2111
Checked for plagiarism Yes
Review by Single-blind
Peer reviewer comments 2
Editor who approved publication: Professor Garry Walsh
Laura Niccoli,1 Carlotta Nannini,1 Corrado Blandizzi,2 Stefania Mantarro,2 Marta Mosca,3 Ombretta Di Munno,3 Delia Goletti,4 Maurizio Benucci,5 Francesca Li Gobbi,5 Emanuele Cassarà,1 Olga Kaloudi,1 Fabrizio Cantini1
1Department of Rheumatology, Hospital of Prato, Prato, Italy; 2Section of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; 3Division of Rheumatology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; 4Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases, Rome, Italy; 5Rheumatology Unit, Hospital S. Giovanni di Dio, Florence, Italy
Objective: To propose appropriate statements that drive the choice of biologic therapies in patients with rheumatoid arthritis (RA), factoring in their impact on the following issues: anti-drug antibody (ADAb) formation, suspicion and management of infections, lupus-like syndrome (LLS), effects on bone mass and sexual sphere, and relationship between RA and periodontal disease (PD).
Methods: An overview of existing evidence was undertaken by an expert panel on behalf of the Italian board for the TAilored BIOlogic therapy (ITABIO). Data were extracted from controlled trials, national registries, national health care databases, post-marketing surveys, and, when required by the paucity of controlled studies, from open-label clinical series. Anti-tumor necrosis factor (anti-TNF) and non-anti-TNF-targeted biologics approved for RA were investigated.
Results: ADAb formation is chiefly associated with anti-TNFs, and it is reduced by combination therapy with methotrexate. To date, ADAb titration is not advisable for clinical practice, and, in case of anti-TNF secondary failure, a non-anti-TNF biologic is indicated. LLS is observed in anti-TNF receivers and, in most cases, resolves without anti-TNF withdrawal. A non-anti-TNF biologic is advisable in patients experiencing LLS. Non-anti-TNFs demonstrated a low or absent infection risk and are preferable in patients with comorbidities. Due to their positive effects on bone mass, anti-TNFs are indicated in women at osteoporosis risk, whereas non-anti-TNF have been poorly investigated. The emerging evidence of the relationship between RA and PD and the effects on anti-TNF efficacy should lead clinicians to consider the periodontal status in RA patients. Anti-TNFs may exert a positive effect on fertility and sexuality, and clinicians should explore these aspects in RA patients.
Conclusion: The optimization of biologic therapies by taking into proper account the above issues would improve patient outcomes.
Keywords: biologics, immunogenicity, infections, lupus-like syndrome, osteoporosis, periodontal disease, sexuality
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