The effect of five approved tumour necrosis factor inhibitors (TNFi: infliximab, etanercept,\nadalimumab, certolizumab, and golimumab) on joint destruction in rheumatoid arthritis (RA) have\nbeen compared versus methotrexate (MTX) in randomized controlled trials (RCTs) but have not\nbeen compared directly to each other or to an otherwise untreated placebo control. The present\nanalysis compares effects of standard doses, high doses, and low doses of TNFis on radiographic\njoint destruction in RA and relate these effects to MTX and placebo by means of a Bayesian network\nmeta-analysis. We identified 31 RCTs of the effect of TNFis on joint destruction and 5 RCTs with\ncontrols, which indirectly could link otherwise untreated placebo controls to the TNFi treatments in\nthe network. The previously untested comparison with placebo was performed to estimate not only\nthe effect relative to another drug, but also the absolute attainable effect. Compared to placebo there\nwas a highly significant inhibitory effect on joint destruction of infliximab, etanercept, adalimumab,\ncertolizumab, and golimumab, which was about 0.9% per year as monotherapy and about 1.2% per\nyear when combined with MTX. Although significantly better than MTX and placebo, golimumab\nseemed inferior to the remaining TNFis. There was no difference between original reference drugs\n(Remicade, Enbrel) and the almost identical copy drugs (biosimilars).
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