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Dean L. PubMed Clinical Q&A [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2008-2013.

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PubMed Clinical Q&A [Internet].

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Comparing Targeted Immune Modulators

, MD.

Created: .

Targeted immune modulators (also referred to as biologics) form a relatively new class of drugs for diseases with chronic inflammation and an inappropriate immune response. Such diseases include rheumatoid arthritis, psoriasis, and inflammatory bowel diseases.

These drugs work by selectively blocking steps in the inflammatory and immune cascades. For example, abatacept and alefacept dampen the immune response by interfering with the activation of T cells, while adalimumab, etanercept, and infliximab target the inflammatory mediator TNF-α.

The "Drug Class Review on Targeted Immune Modulators" compares the safety and effectiveness of twelve drugs. A summary of the findings is below.

How do targeted immune modulators compare in arthritis?

In adults with rheumatoid arthritis, abatacept and infliximab work similarly well for up to 6 months, but there are fewer serious adverse events and infections linked with abatacept.

For other drugs, there is limited evidence that suggests adalimumab has greater response rates compared to infliximab and etanercept compared to abatacept, anakinra, infliximab and tocilizumab. No differences were found between adalimumab and etanercept.

There are no direct comparisons of targeted immune modulators for treating juvenile idiopathic arthritis, but the small studies available suggest that abatacept, adalimumab, etanercept, infliximab, and tocilizumab are superior to placebo. [full review]

How do targeted immune modulators compare in ankylosing spondylitis?

Adalimumab, etanercept, golimumab, and infliximab are superior to placebo in treating moderate to severe ankylosing spondylitis. When compared indirectly, findings suggest no significant differences in the treatment response rates among these drugs. [full review]

How do targeted immune modulators compare in psoriasis?

Targeted immune modulators are used to treat both the skin disorder (plaque psoriasis) and joint disorders (psoriatic arthritis) caused by psoriasis.

Adalimumab, alefacept, etanercept, infliximab, and ustekinumab are superior to placebo in treating moderate to severe plaque psoriasis. When compared indirectly, findings suggest no significant differences in the treatment response rates among adalimumab, etanercept, and infliximab. [full review]

How do targeted immune modulators compare in inflammatory bowel disease?

For adults with moderate to severe Crohn's disease, adalimumab, certolizumab pegol, infliximab and natalizumab are superior to placebo in achieving remission.

In adults with active ulcerative colitis, limited evidence suggests infliximab is superior to placebo in achieving clinical remission. [full review]

How do targeted immune modulators compare in safety?

There is a lack of data on how these drugs compare in safety, and a lack of long-term data because drugs such as alefacept, natalizumab, and rituximab are relatively new.

In general, compared to placebo, targeted immune modulators appear to be well tolerated but have a potential for rare but serious adverse events such as infections, cancer, or hematological disorders. Injection site or infusion reactions are among the most commonly reported adverse events.

Overall, the rates of adverse events appear to be similar among most drugs. Observational evidence and one trial suggest that infliximab has a greater risk for adverse events than abatacept, adalimumab, and etanercept. Indirect evidence suggests the risk of patients discontinuing treatment due to adverse events is higher for infliximab compared with abatacept, adalimumab, etanercept, and golimumab. [full review]

Does age or gender influence the safety or effectiveness of targeted immune modulators?

Indirect evidence suggests that age does not influence clinical response rates or the safety of these drugs in adults with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis. However, one study found the response to treatment with etanercept and infliximab in adults with rheumatoid arthritis was better in patients younger than 65 years.

For adverse events, one report found that the only difference between older and younger patients was that bacterial pneumonia was more common in adults in their 70s than those in their 50s. [full review]

Drugs included in this review

Generic NameTrade Names
Certolizumab pegolCimzia

Further Information

Image th-immmod09.jpgThis PubMed Clinical Q&A was reviewed by Gerald Gartlehner, MD, MPH.

For the full report and evidence tables, please see:
Thaler KJ, Gartlehner G, Kien C, Van Noord MG, Thakurta S, Wines RCM, Hansen RA, McDonagh MS. Drug Class Review on Targeted immune modulator [Internet]. Portland (OR): Oregon Health & Science University; 2012. Available at