Quality of Life Benefits for TNF-Blockers vs. DMARDs

ACR Special Report


Stephen A. Paget, MD, FACP, FACR

Physician-in-Chief Emeritus, Hospital for Special Surgery

That TNF-blocking agents are highly effective compared to traditional DMARDs in reducing joint erosions has been well-documented in clinical trials and has been the main focus of physician attention. Less attention has been focused on the benefit of the newer drugs on the parameters that matter most to patients: fatigue and general well being.

At the recent ACR meeting, Kvien et al reported on the relative effectiveness of TNF-blockers and traditional DMARDs on clinical outcomes in a six-month "real life" longitudinal observation study[1]. A total of 1,174 Norwegian patients, mean age 52.8 years, with inflammatory arthropathies were enrolled, of whom 1015 were on DMARDs, including methotrexate (421), leflunomide (163), sulfasalazine (186), other monotherapies (137), and combination therapies without TNF (108), while 151 were on TNF agents.

"Changes in patient health status measures were evaluated by the standard response mean (SRM), reported the authors. "The relative magnitude of responses was computed as a ratio between the SRM for the TNF and DMARD groups, i.e. the higher the ratio, the relatively larger the magnitude of response with TNF-blocking agents compared to DMARD regimes."

Many of the TNF-blocker to DMARD ratios for the relative effectiveness on the various health status measures were clinically significant: fatigue 5.90, general health 5.80, social functioning 2.64, mental health 2.56, physical functioning 2.40, pain 2.46, energy 2.22, patient global score 2.18, and MHAQ, 2.14. These ratios are highly supportive of the fact that TNF-blockade use significantly improves the patients' feeling of well-being compared to the simple DMARDs and yield an overall better quality of life.

While this concept has been picked up to a degree in regular TNF studies that have included evaluation of MHAQ scores, they have not been as comprehensive in their approach and have largely compared TNF-blockers plus MTX to MTX. Thus, this study gives us a wider view.

The addition of a significant improvement in quality of life issues and clinical outcomes to an overall improvement in the development of damage, which other studies have shown for TNF-blockers over MTX alone, defines an optimal therapy in a systemic disease that not only affects joints but the rest of the body.

From the patient's point of view, anti-TNF therapy gets the priorities right - because patients don't know their joints are less eroded unless we tell them. Patients know they have less fatigue and are enjoying life.


[1] Kvien TK, Mikkelsen K, Nordvåg B, Kaufmann C, Rødevand E, Mowinckel P. The Relative Effectiveness of TNF-blocking Agents and Traditional DMARDS on Clinical Outcomes: Results from a Longitudinal Observational Study Arthritis Rheum. 2003 Sep;48(9):S612. Abstract #1590.
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