As Americans we seem to be obsessed with the idea of selecting the best in category. Which hybrid suv has the best gas mileage. Which doctor is the top doctor In his field in your city. Which city has the best commute. Which local Thai restaurant makes the best pad Thai. Forget about whether these judgements are even reliable or just opinion polls. Can this grading process be used in evaluating different treatments for different medical conditions?
The last 15 years have seen an explosion of new treatments for rheumatoid arthritis. These treatments are legitimately life altering and have completely rewritten entire textbooks on prognosis and expectations for RA patients. But until lately, it hasn’t been possible to say whether amongst the newer treatments which one is the best or most appropriate for an individual. This is partly due to different studies varying in methodology, tested end points, and patient populations. But recently a number of articles have been published directly comparing different medications in head to head trials.
We’ve recently heard that actemra monotherapy is superior to humira monotherapy. We’ve separately also seen that orencia and humira are very similar in efficacy. Various European registries have suggested that enbrel and humira are more favorable compared to remicade. But a recent report from a large US database suggests that remicade gives more persistent results than enbrel and humira.
I know what you’re thinking- this isn’t what I expected either when I heard that head to head trials were being done. What happened to anointing one treatment as the best? It turns out that issues beyond simply prescribing medication are involved. Dosages of some meds were not exactly equivalent between all studies. This may have been partially driven by reluctance of different healthcare systems to pay for higher dosages of these expensive meds. Not to mention doctors and patients in the US may differ in unclear ways compared to their cohorts in different European countries. In other words, it’s complicated. We still don’t have one winner here. While this will drive healthcare administrator types crazy, as a clinician it’s good to know that I still have lots of really good and possibly equivalent treatments for my patients. These studies will not change the way I practice yet. But we’re headed in the right direction.