Not all TNF inhibitors in rheumatoid arthritis are created equal: important clinical differences

ABSTRACT

Introduction: Anti-TNF therapy has dramatically changed how we manage rheumatoid arthritis. There are many similarities among the five approved agents but also some important differences. Rheumatologists have 5 different options to choose from when they are ready to commence anti-TNF therapy. Although all block the TNF cytokine, there are important critical differences among them that affect their safety profile and clinical utility in certain scenarios. Unfortunately, there are no head to head trials to compare the different anti-TNF agents and none appear to be in the horizon.

Areas covered: This article reviews the various clinical situations where it may be important to use a particular anti-TNF agent. The authors also give their expert opinion and future perspectives on the area.

Expert opinion: Although there are many similarities among the five different TNFi that are clinically available, there are important clinical niches, where the limited data that are available, that clearly support the preferential use of a particular agent or class of agents. Assays or tests that allow us to find the ‘sweet spot’ of TNF inhibition at the level of each patient are long overdue.

KEYWORDS:

• Anti TNF
• rheumatoid arthritis
• customization
• biologics

Article highlights

• Infectious complications including bacterial infections increase with increasing doses of TNFi, which is best studied with infliximab.

• Patients at high risk for certain infections (TB, histoplasmosis, coccidioidomycosis) should preferentially receive etanercept over the mono-clonal antibodies.

• Patients with RA inflammatory eye disease should get a monoclonal antibody over etanercept.

• When anti-drug antibodies (ADA) are a concern there is a clear advantage of etanercept over the monoclonal antibodies (infliximab and adalimumab).

• In a pregnant RA patient, there are theoretical advantages of using certolizumab.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This manuscript has not been funded.