By Douglas E. Young and Michael S. Kudlacz
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Trial was between etanercept (two doses) and methotrexate, whereas the ATTRACT trial compared methotrexate with infliximab plus methotrexate. Concomitant methotrexate with infliximab is warranted because of the immunogenicity of infliximab (which incorporates part of a mouse IgG molecule); methotrexate appears to decrease the formation of antibodies to the chimeric antiTNF antibody. Etanercept, being wholly human (p75—human Fc) does not require this co-treatment. This might explain why some degree of progression of erosion was still measurable in the etanercept group, whereas erosion scores in the ATTRACT study barely progressed over 54 and 102 weeks in the infliximab plus methotrexate group.
How applicable this particular finding is to RA is questionable. Conclusion These findings suggest that anti-TNF treatment not only alters the cytokine profile but affects cellular infiltration, adhesion molecule expression and the Tcell cytokine balance. It also shows that the anti-CD4 treatment’s lack of efficacy is in part attributable to a failure to eliminate CD4+ T cells from the joint and in part due to persistent IFN-γ production by activated T cells. Finally, combination treatment exerts synergistic effects in this particular model.
Etanercept was well tolerated. INTERPRETATION. Etanercept is safe and effective in psoriatic arthritis, and offers patients a new therapeutic option for the control of their disease. Comment Similar encouraging reports have appeared in abstract form on the treatment of psoriatic arthritis with infliximab. Since psoriatic arthritic may on occasion be difficult to treat and resistant to agents which are effective in RA, an additionaltherapeutic option is very welcome. The comparison with placebo, while necessary in assessing treatment, is not the most relevant one for every day practice, and comparison with methotrexate will be valuable.
