Case-Based Approach for the Management of Rheumatic Diseases - Episode 14
Transcript: Grace C. Wright, MD, PhD: Within the TNF [tumor necrosis factor] world, there are a variety of choices. If we go back to some of the earlier ones, we had adalimumab as a monoclonal antibody protein, etanercept as an infusion, and also infliximab, which is another monoclonal. After that we had golimumab both as a subcutaneous form and as an intravenous form. Finally, certolizumab is a pegylated subcutaneous, whether it’s physician administered or patient administered. Across all these we’re looking at something that is going to block the TNF pathway. How do they differ? Look across the entire class: These are all very effective drugs. Some patients may prefer 1 over the other. For instance, there are data with certolizumab looking at transfer across the placenta, transfer in breast milk. For a young woman that may be an option, because if she’s trying to get pregnant or is pregnant, she may prefer something that may not cross the placenta and get into her baby.
In terms of efficacy, there are lots of data with adalimumab, etanercept, and infliximab, so there are lots of choices across that spectrum. Some of these agents can be used as monotherapy, meaning no background therapy required, and the most common background therapy is methotrexate. I may have someone who cannot use methotrexate because they’ve had toxicity or adverse effects—liver damage, her cell counts are low, she’s losing her hair. A 31-year-old going bald with methotrexate is not so inviting. But outside that, some people get nauseated and very fatigued. Not everyone can tolerate methotrexate, so we look for those agents that we have substantial evidence that they are effective and sustainable in the absence of methotrexate. TNF inhibitors are a class. Then we have the IL-23 inhibitors. Ustekinumab is the prominent 1 that we’ve had for some time. It really has been used for psoriasis extensively and more now with psoriatic arthritis, with efficacy being shown there in various routes of administration with ustekinumab. Finally, in the IL-17 inhibitor class, we have ixekizumab and secukinumab, both inhibitors of IL-17 and both with data that show effectiveness in the skin and in the joints with or without methotrexate.
There are lots of efficacy data and lots of discussions about what’s going to work best. There are data showing even superiority, in some cases, of 1 drug class over another in certain studies. But for that individual patient, that’s a discussion based on her choice.
Transcript Edited for Clarity