Table 16Summary of findings

Key ComparisonsEfficacy and Effectiveness
Strength of Evidence Grade
Harms
Strength of Evidence Grade
Oral DMARDs
LeflunomideNo head-to-head studies met inclusion criteria; unable to draw conclusions on the comparative efficacy of leflunomide and other treatments.
INSUFFICIENT
Compared with placebo in one study, leflunomide produced better improvement in health-related quality of life and statistically significant, but not clinically significant, improvement in disease activity and functional capacity.
LOW
No head-to-head studies met inclusion criteria; unable to draw conclusions on the comparative harms of leflunomide and other treatments.
INSUFFICIENT
Current evidence was limited to placebo-controlled trials. Compared with placebo, leflunomide led to higher rates of withdrawals because of adverse events, diarrhea, and clinically significant increases in alanine aminotransferase.
INSUFFICIENT
MethotrexateNo head-to-head studies met inclusion criteria; unable to draw conclusions on the comparative efficacy of MTX and other treatments.
INSUFFICIENT
Current evidence was limited to placebo-controlled trials. Compared with placebo in one fair study, MTX resulted in greater improvement in physician assessment of disease activity than placebo.
LOW
No head-to-head studies met inclusion criteria; unable to draw conclusions on the comparative harms of MTX and other treatments.
INSUFFICIENT
SulfasalazineNo head-to-head studies met inclusion criteria; unable to draw conclusions on the comparative efficacy of sulfasalazine and other treatments.
INSUFFICIENT
Current evidence was limited to placebo-controlled trials. Compared with placebo in one good systematic review study, sulfasalazine reduced disease activity.
MODERATE
No head-to-head studies met inclusion criteria; unable to draw conclusions on the comparative harms of sulfasalazine and other treatments.
INSUFFICIENT
Biologic DMARDs
Biologic DMARD + Oral DMARD vs. Biologic DMARD or Oral DMARDThe current evidence was limited to two cohort studies. Compared to anti-TNF monotherapy (adalimumab, etanercept, or infliximab), MTX plus anti-TNF produced similar disease activity response rates.
LOW
One systematic review of TNF inhibitors found that both TNF inhibitors and sulfasalazine are effective (similar withdrawals due to lack of efficacy); however, the data were insufficient to determine if the effect reached MCID.
INSUFFICIENT
No head-to-head evidence met inclusion criteria; unable to draw conclusions on the comparative harms of biologic DMARD + oral DMARD and other treatments.
INSUFFICIENT
BiologicNo head-to-head trials met inclusion criteria; unable to draw conclusions on the comparative efficacy of biologics and other treatments.
INSUFFICIENT
Compared with placebo, adalimumab, etanercept, golimumab, and infliximab led to greater improvement in disease activity, functional capacity* and health-related quality of life.
LOW to MODERATE
Etanercept had a lower rate of withdrawals because of adverse events than infliximab in a prospective cohort study.
LOW
Additional evidence was limited to placebo-controlled trials, where adverse events were not the primary outcome. Overall adverse event profiles appeared to be similar for biologic DMARDs and placebo. However, compared with placebo, we noted the following: adalimumab and etanercept had more injection-site reactions and adalimumab had fewer events of aggravated psoriasis than placebo
LOW
Golimumab was associated with more malignancies than placebo in one RCT
INSUFFICIENT

ADA = adalimumab; DMARD = disease-modifying antirheumatic drug; ETN = etanercept; INF = infliximab; LEF = leflunomide; MCID = minimal clinically important difference; MTX = methotrexate; PCS = physical component score; SF-36 = Medical Outcomes Study Short Form 36; SSZ = sulfasalazine; TNF = tumor necrosis factor

*

Of seven studies reporting outcomes for the Health Assessment Questionnaire (HAQ), the magnitude of benefit in functional capacity compared with placebo reached the MCID (HAQ change of ≥ 0.22) for all but one study of adalimumab (which found a between-group difference of 0.2).a The magnitude of benefit for functional capacity (between-group difference for improvement in HAQ) ranged from 0.2 to 0.3 for adalimumab, 0.5 to 1.1 for etanercept, 0.34 to 0.4 for golimumab, and 0.4 to 0.6 for infliximab.

The magntude of benefit in quality of life reached the MCID for the SF-36 PCS for all five studies that reported the PCS and ranged from 2.9 to 7.9 for adalimumab, 8.6 for etanercept, 5.9 to 7.2 for golimumab, and 6.4 to 8 for infliximab.

Low for golimumab and moderate for adalimumab, etanercept and infliximab.

From: Discussion

Cover of Drug Therapy for Psoriatic Arthritis in Adults: Update of a 2007 Report
Drug Therapy for Psoriatic Arthritis in Adults: Update of a 2007 Report [Internet].
Comparative Effectiveness Reviews, No. 54.
Donahue KE, Jonas D, Hansen RA, et al.

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