Adalimumab: new preparation. Rheumatoid arthritis: no therapeutic advance

(1) There is no agreed treatment for patients with rheumatoid arthritis in whom first-line options, including methotrexate, have failed. Recent slow-acting antirheumatic drugs have not been compared with one another, but they seem to have similar risk-benefit ratios. Etanercept, a TNF-alpha antagonist, is the most convenient to use. (2) Adalimumab is the third TNF-alpha antagonist to be marketed in France for use in rheumatoid arthritis, after etanercept and infliximab. (3) The clinical evaluation dossier mentions no data from comparative trials with other slow-acting antirheumatic drugs used in refractory rheumatoid arthritis. (4) Placebo-controlled trials show that adalimumab alone has very modest efficacy. The best results are obtained when adalimumab is combined with methotrexate. On the basis of the least demanding criterion (ACR 20%), about two-third of patients are improved by this combination. (5) Clinical trials show that it is pointless to continue treatment with adalimumab for more than three months if efficacy is inadequate. (6) Adalimumab, like other TNF-alpha antagonists, can have potentially serious adverse effects, linked mainly to its immunosuppressive action. Opportunistic infections and cases of tuberculosis have been reported, even during short treatment periods. Many questions remain regarding long-term treatment effects, such as the risk of lymphoma, autoimmune disorders, and onset or aggravation of demyelinising diseases. (7) Adalimumab is given once every two weeks, subcutaneously, while etanercept 25 mg is given as two subcutaneous injections per week, and infliximab is given as an intravenous infusion every 8 weeks. (8) In practice, for patients with rheumatoid arthritis who do not respond to methotrexate and to other classical slow-acting antirheumatic drugs, etanercept is the best choice among recent slow-acting antirheumatic drugs.