Efficacy of biologic agents in improving the Health Assessment Questionnaire (HAQ) score in established and early rheumatoid arthritis: a meta-analysis with indirect comparisons.

Objective The Health Assessment Questionnaire (HAQ) is a validated physical function measure. It is predictive for disability and mortality. The objective of this study was to determine the comparative efficacy of biologic agents in improving HAQ in patients with established RA who failed DMARDs or anti-TNF agents and in early RA (ERA). Methods We performed random effects meta-analyses of published randomised, placebo-controlled trials. Outcome was the mean difference in change in HAQ for biologic agents compared to controls (Delta HAQ(B)-Delta HAQ(C)). Indirect comparisons of the different biologic drugs were conducted using the Q-test based on analysis of variance. Meta-regression was performed using the method of moments. Results Twenty-eight trials were included: 19 with DMARD-failures; 4 with anti-TNF-failures and 5 ERA. The following biologics were represented: abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab and tocilizumab. Efficacy of biologics at reducing HAQ was significantly different based on prior treatment (p=0.001). In RA patients with DMARD failures, Delta HAQ(B)-Delta HAQ(C) was -0.22; 95%CI: -0.24, -0.20 (I-2=55%). Infliximab, abatacept and tocilizumab had lower Delta HAQ(B)-Delta HAQ(C) compared to other biologics (p<0.02). In anti-TNF-failures, Delta HAQ(B)-Delta HAQ(C) was -0.36; 95%CI: -0.42, -0.30 (I-2=0%). In ERA, methotrexate-naive trials, Delta HAQ(B)-Delta HAQ(C) was -0.19; 95% CI: -0.26, -0.13 (I-2=0%). There were no significant differences in the efficacy of different biologics for anti-TNF failures and ERA. Conclusions Biologic agents were efficacious at lowering HAQ in RA. Differences between agents in RA with DMARD failures were less than the minimally clinically important difference for HAQ; therefore, the clinical significance of these differences is unclear.