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Rheumatology Advance Access first published online on September 29, 2006
This version published online on October 2, 2006
Rheumatology, doi:10.1093/rheumatology/kel326
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Received July 20, 2006
Accepted August 15, 2006

Concise Report

Dose escalation of the anti-TNF-{alpha} agents in patients with rheumatoid arthritis. A systematic review

R. Ariza-Ariza 1, F. Navarro-Sarabia 1 *, B. Hernández-Cruz 1, L. Rodríguez-Arboleya 1, V. Navarro-Compán 1, and J. Toyos 1

1 Rheumatology Service, Hospital Universitario Virgen Macarena, Seville, Spain

* To whom correspondence should be addressed.
F. Navarro-Sarabia, E-mail: federiconavarro{at}supercable.es


  Abstract

Objective. To estimate the proportion of rheumatoid arthritis (RA) patients on anti-tumour necrosis factor (anti-TNF) who require dose escalation.

Methods. Systematic review of the scientific literature. Infliximab, etanercept and adalimumab studies in RA were considered. Primary outcome was the proportion of patients requiring dose escalation. American College Rheumatology (ACR) and Disease activity score (DAS) responses post-escalation were assessed when available.

Results. From 1801 references, 16 studies with 8510 patients were included. Of all the infliximab patients, 53.7% underwent dose escalation. Fourty-four per cent of the infliximab patients experienced dose increase and 8.3%, frequency increase. The ACR20 response to dose escalation ranged from 27 to 36% and DAS28 improved from 5.2 to 4.5 in one study and from 4.1 to 3.7 in another. Of the etanercept patients, 17.5% experienced a dose increase but changes on the mean dose were not statistically significant.

Conclusions. Dose escalation is common in patients treated with infliximab, and less frequent with etanercept. In a proportion of patients, the dose escalation seems effective. The design and evidence level of the available studies limit the strength of the conclusions.

Keywords: Rheumatoid arthritis; Anti-TNF agents; Dose escalation.
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Dose escalation of infliximab therapy in arthritis patients is related to diagnosis and concomitant methotrexate treatment: observational results from the South Swedish Arthritis Treatment Group register
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