A systematic review of the effectiveness of adalimumab

60
Effectiveness
per week and escalated to up to 25 mg per week
depending on disease activity) and methotrexate
combined with infliximab 3 mg kg –1 i.v. every
8 weeks. Patients with early RA, judged to have a
poor prognosis, were treated for 12 months, with a
further open-label phase up to 24 months. The
latter data are not included in this review as other
DMARDs could be introduced during the
extension. RA patients with symptoms for less
than 12 months and no previous treatment with
DMARDs or oral corticosteroids were recruited.
Metacarpophalangeal joint disease and poor
prognosis according to a scoring system based on
rheumatoid factor positivity, genetic markers, CRP,
gender and HAQ score were required. The
primary end-point was MRI-measured synovitis at
week 14. Allocation concealment was not clearly
stated.
BeSt: Goekoop-Ruiterman and
colleagues 108,143,144
This important trial compared four strategies for
using DMARDs, rather than individual drugs.
Patients with RA diagnosed within 2 years were
recruited. Because patients received infliximab in
all arms, this trial does not meet the inclusion
criteria defined in the current protocol, which
sought comparative studies of TNF inhibitors
against alternative treatments. Nor can its results
be incorporated meaningfully in the metaanalyses.
Nevertheless, it is reported in detail
here, as it is important evidence to inform
guidance on appropriate use of infliximab. The
primary end-points of BeSt were HAQ and
radiographic joint damage according to the van
der Heijde modified Sharp score after 1 year of
follow-up. A sequence of drug treatments was
strictly defined and patients moved along the
sequence of therapies based on their response.
Those who did not achieve a DAS of 2.4 or less,
based on evaluation of 44 joints (Appendix 1),
moved to the next step in the defined sequence. A
sustained response to therapy, defined as DAS of