Neue Studien

Intraarticular etanercept vs corticosteroid in rheumatoid arthritis

Roux CH et al.
Etanercept Compared to Intraarticular Corticosteroid Injection in Rheumatoid Arthritis: Double-blind, Randomized Pilot. J Rheumatol
First Release March 15 2011; doi:10.3899/jrheum.100828.

Objectives
To compare the benefits of an intraarticular injection of etanercept alone vs regular corticosteroids for persistent monoarthritis in treated rheumatoid arthritis.

Methods
A randomized double-blind controlled pilot trial comparing the benefits at 4 and 24 weeks, in terms of target joint pain, of intraarticular etanercept (E) alone (25 mg) or betamethasone (B) alone (4 mg, equivalent to 16 mg triamcinolone) for persistent monoarthritis of the knee, ankle, elbow or wrist. Injections were carried out with a radioscopic control, and all analyses were performed using an intention-to-treat model.

Results
Of 41 eligible patients, 34 accepted to participate and were randomized equally to each group. 8 patients were prematurely excluded for a flare of the disease, 4 in each group. Clinical characteristics were similar at baseline between groups, while target joints were knee (11), ankle (4), wrist (14) and elbow (5). The primary efficacy outcome did not show any difference, with no difference in target joint VAS between the treatment groups at weeks 4 or 24 (p = 0.9 for both). Both treatments work equally well to decrease pain, with a similar mean decrease in joint pain VAS from baseline (etanercept: -27.9 (SD 29.0) at wk 4 / -24.7 (SD 8.7) at wk 24 ; bethamethasone: - 29.9 (SD 30.1) at wk 4 / -22.8 (SD 8.8) at wk 24. Treatment did not result in different outcomes, at both time points, in terms of DAS28 score, ESR, HAQ or synovial thickness as evaluated by ultrasonography.

Conclusion
Both etanercept and corticoid intraarticular injections resulted in a significant improvement at 4 and 24 weeks post-injection in persistent monoarthritis, but there was no significant difference in outcome measures between the groups.

Commentary
A small pilot study with the benefits to be randomized, controlled and even with secure needle placement, that confirms the absence of added benefits of intra-articular anti-TNF (in this case etanercept) injection over a simple injection of intra-articular corticosteroids. Both treatments are equivalent in terms of efficacy, and the cost-risk to benefit ratio is clearly in favor of corticosteroids. While etanercept did demonstrate some efficacy, its use should definitively be reserved for the very rare cases of absolute contraindication to intra-articular corticosteroids, or eventually after failure of the latter, when the only alternative is the systemic administration of the same biologic in a very limited disease, where a desperate try would appear reasonable.

Jean Dudler, Fribourg

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