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Assessment of factors relevant to the NHS and other parties

The results of this technology assessment have some implications for clinical practice. At present, most patients with PsA who receive biologic therapy are managed by a rheumatologist. However, patients with PsA primarily concerned with improvements in their skin may benefit from being managed by a dermatologist who can tailor any ongoing topical therapy appropriately. Some patients with severe skin and joint disease may need dual management of both specialties, although it has implications in terms of additional administration, costs and communication between the specialties and primary care.

List of abbreviations

All abbreviations that have been used in this report are listed here unless the abbreviation is well known (e.g. NHS), or it has been used only once, or it is a non-standard abbreviation used only in figures/tables/appendices, in which case the abbreviation is defined in the figure legend or in the notes at the end of the table.


This monograph is based on the Technology Assessment Report produced for NICE. The full report contained a considerable amount of data that was deemed commercial-in-confidence and academic-in-confidence. The full report was used by the Appraisal Committee at NICE in their deliberations. The full report with each piece of commercial-in-confidence and academicin-confidence data removed and replaced by the statement ‘commercial-in-confidence and academic-in-confidence information (or data) removed’ is available on the NICE website:www.nice.org.uk.

Definition of decision problem

The use of biologics in inflammatory disease is a rapidly evolving area. Etanercept and infliximab were previously evaluated together for their efficacy and safety in PsA in 2006 and adalimumab was separately evaluated more recently. There is a need for an up-to-date evaluation of all three biological agents that are licensed for use in the treatment of PsA.


The limited data available indicate that etanercept, infliximab or adalimumab are efficacious in the treatment of PsA compared with placebo, with beneficial effects on both joint and skin symptoms and on functional status. Short-term data suggest that these three biologic agents can delay joint disease progression.


We would like to thank the following for their assistance in providing additional data or advice: Suzanne Verstappen and Deborah Symmons at the ARC Epidemiology Unit, University of Manchester, for analyses of the NH of PsA; Carolyn Davies for advice on the costs of biologics; Darren Ashcroft at the University of Manchester for an advance draft of an article submitted for publication and additional analyses; Neil Hawkins at Oxford Outcomes for advice on accounting for placebo effects; and the manufacturers who provided additional data where requested.

NIHR Health Technology Assessment programme

The Health Technology Assessment (HTA) programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. ‘Health technologies’ are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care.


The systematic review of clinical efficacy found a limited amount of high-quality data suggesting that etanercept, infliximab and adalimumab all produce significant improvements in joint response measures relative to placebo. Some evidence suggesting beneficial effects for these agents in terms of skin response, although data on this outcome are sparse. Although short-term data on joint progression are promising, longer-term controlled data on this outcome are lacking. The range of incidences of serious adverse events did not appear to differ remarkably between agents.

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