Y. Oishi

AB0379 Tapering or Stopping of Methotrexate in Non-Tumor Necrosis Factor Therapy (Tocilizumab and Abatacept) in Patients with Rheumatoid Arthritis

Background Non-tumor necrosis factor (TNF) agents, such as tocilizumab (TCZ) and abatacept (ABT), were widely used in the treatment of rheumatoid arthritis (RA). It seems that non-TNF agents are slightly different from anti-TNF agents in respect to dependency on methotrexate (MTX). Although MTX is a very important concomitant drug in anti-TNF therapy, MTX may not be so in non-TNF therapy for majority of patients. MTX have many severe adverse events (AE) such as interstitial pneumonia, severe infection, and myelosuppression. Tapering or stopping of MTX have been tried in our institute to avoid AE of MTX when RA patients treated with non-TNF agents reached at sustained remission. We report the preliminary results of MTX tapering in non-TNF therapy in this study. Objectives This retrospective study evaluated tapering or stopping of MTX in non-TNF therapy (TCZ and ABT) and impact of it to RA treatment in clinical practice. Methods 27 RA patients who initiated TCZ or ABT with concomitant MTX and continued non-TNF agents for 2 years were used. Time-course of disease activity (DAS28-CRP and CDAI), arthritis marker (serum MMP-3), activity of daily living (mHAQ), joint destruction (ΔmTSS per a year) and tapering concomitant drug (MTX and prednisolone) were investigated. MTX was tapered depending on physicians decisions and stopped if possible. Results 20 females and 7 males with mean age of 60 years were used in this study. Mean RA duration was 11.8 years. TCZ was continued for 2 years in 16 cases and ABT in 11 cases. MTX of mean dosage of 9.0mg/week (4.0–16.0 mg/w) was prescribed in all patients at baseline. Mean DAS28-CRP was 4.57 at baseline, 2.26 at 1 year and 2.00 at 2 years. There were significant decreases not only from baseline to 1 years (p<0.0001) but also from 1 year to 2 years (p=0.04). Significant decrease and sustainment were also observed in CDAI, serum MMP-3 and mHAQ) (Fig. 1). Although ΔmTSS at baseline was )10.0, it was significantly improved to 1.5 from baseline to 1 year (p=0.0001) and to 0.5 from 1 year to 2 years (p<0.0001). Mean MTX dosage was significantly decreased from 9.0mg/w at baseline to 4.8mg/w at 1 year (p=0.0003) and to 2.9mg/w at 2 years (p<0.0001). There was a significant difference of MTX dosage between at 1 year and 2 years (p=0.049). Although MTX was concomitant in all patients at baseline, it was used in only 66.7% at 1 year and only 40.7% at 2 year. Mean PSL was also tapered from 3.5mg/day at baseline to 1.2mg/d at 2 years (Fig. 2). Similar trends were observed in both patients treated with TCZ and ABT. Conclusions This study suggested that concomitant MTX may be tapered or stopped in RA patients treated with TCZ or ABT and reached to sustained remission without worsening disease activity and joint destruction. Information of prospective large studies was necessary in the future. Disclosure of Interest None declared

FRI0254 Efficacy of tocilizumab for suppressing radiographic progression of cervical lesions in patients with rheumatoid arthritis comparison with methotrexate treatment; two years of follow-up ∼a multicenter registry study ∼

Background Cervical lesions are known to occur at high frequency as a complication of rheumatoid arthritis (RA). Treatment with biological agents are more clinically effective than the DMARDs that were in use previously, in particular, with their efficacy in suppressing joint destruction having been emphasized. We reported the efficacy of infliximab (IFX), anti-tumor necrosis factor antibodies for suppressing the radiographic progression of RA cervical lesions at ACR2009, EULAR2010, 11, 12, 13 and 14. However there is still few studies of efficacy of against RA cervical lesions of IFX comparison with methotrexate (MTX). Objectives To evaluate the efficacy of IFX for suppressing the radiographic progression of RA cervical lesions comparison with MTX for 2 years. Methods We used MTX or MTX+IFX for treating Japanese patients with active RA who fulfilled the ACR criteria in 1987. The final study cohort of each 40 and 88 patients received continuous MTX and IFX treatment for at least 2 years. MTX was used in all patients receiving IFX. For evaluation of cervical lesions, the atlanto-dental interval (ADI), the space available for the spinal cord (SAC), and the Ranawat value were measured by plain lateral radiographs in the flexion position, at initiation and Year 1,2. Results In the patients receiving MTX (n=40) and IFX (n=88), the number of female were each 33 (83%) and 75 (85%) cases (p=0.794). The mean age was 62.5 ± 10.7 and 53.9 ± 12.9 years old (p<0.001); disease duration was 9.3 ± 10.0 and 10.7 ± 9.2 years (p=0.127) and the mean dose of MTX was 7.3 ± 2.4 and 7.8 ± 2.1 mg/w (p=0.414). Clinical findings related to RA were as follows; CRP 1.3± 2.0 and 3.1± 2.8 mg/dl (p<0.001); ESR 28.1 ± 21.1 and 49.9 ± 29.1mm/h (p<0.001); MMP3 170 ± 303 and 337 ± 309ng/ml (p<0.001); DAS28 4.07 ± 1.42 and 5.47 ± 1.25 (p<0.001); ADI 2.6 ± 1.6 and 3.6 ± 1.9mm (p=0.001); SAC 20.2 ± 2.7 and 18.1 ± 2.7mm (p<0.001) and Ranawat value 16.0 ± 1.5 and 14.5 ± 2.2mm (p<0.001). The respective changes in cervical lesion parameters after 1 year were as follows: ADI: 0.25 ± 0.44 and 0.22 ± 0.44 mm (p=0.591); SAC: −0.18 ± 0.39 and −0.16 ± 0.40 mm (p=0.716); and Ranawat value: −0.13 ± 0.34 and −0.15 ± 0.36 mm (p=0.733). The respective changes in cervical lesion parameters after 2 years were as follows: ADI: 0.53 ± 0.72 and 0.35 ± 0.59 mm (p=0.193); SAC: −0.48 ± 0.64 and −0.27 ± 0.60 mm (p=0.038); and Ranawat value: −0.35 ± 0.58 and −0.26 ± 0.47 mm (p=0.486) (Fig. 1). The numbers of patients who did not showed progression in ADI, SAC and Ranawat value were each 24 (60%) and 62 (70%) cases (p=0.310); 24 (60%) and 67 (76%) cases (p=0.058) and 28 (70%) and 66 (75%) cases (p=0.666) after 2 years. Also the number who was able to suppress progression in all three parameters were each 24 cases (60%) receiving MTX and 58 cases (66%) receiving IFX (p=0.555) after 2 years (Fig. 2). Conclusions This study suggested that IFX treatment can be used to suppress the progression of RA cervical lesions more than MTX treatment. Disclosure of Interest Y. Kanayama: None declared, T. Kojima Speakers bureau: Mitsubishi Tanabe Pharma, Takeda Pharma, Eisai Pharma, AbbVie,Bristol-Myers Squibb, and Pfizer, Janssenn Pharmaceutical Companies, Astellas Pharma and Chugai Pharma., Y. Hirano Speakers bureau: Abbvie Japan, Eisai, Mitsubishi Tanabe Pharma, Pfizer, Chugai Pharmaceutical, and Bristol-Myers Squibb., N. Takahashi Speakers bureau: Abbvie Japan Co. Ltd, Eisai Co. Ltd, UCB Japan Co. Ltd, Mitsubishi Tanabe Pharma Corporation, Takeda Pharmaceutical Company Ltd, Pfizer Co. Ltd, Chugai Pharmaceutical Co. Ltd,Janssen Pharmaceutical K.K., and Bristol-Myers Squibb Co. Ltd., Y. Yabe: None declared, N. Ishiguro Grant/research support from: Daiichi Sankyo, Takeda Pharmaceutical, Hisamitsu Pharmaceutical, Otsuka Pharmaceutical, TaishoToyama Pharmaceutical, Kaken Pharmaceutical, Eisai, Janssen Pharmaceutical, Bristol-Myers Squibb, AbbVie, Chugai Pharmaceutical, Mitsubishi Tanabe Pharmaceutical, Astellas Pharma, and Pfizer Japan, Speakers bureau: Daiichi Sankyo, Takeda Pharmaceutical, Hisamitsu Pharmaceutical, Otsuka Pharmaceutical, Taisho Toyama Pharmaceutical, Kaken Pharmaceutical, Eisai, Janssen Pharmaceutical, Bristol-Myers Squibb, AbbVie, Chugai Pharmaceutical, Mitsubishi Tanabe Pharmaceutical, Astellas Pharma, and Pfizer Japan.

AB0452 Efficacy of TOCILIZUMAB for Suppressing Radiographic Progression of Cervical Lesions in Patients with Rheumatoid Arthritis from Japanese Tbcr

Background Cervical lesions are known to occur at high frequency as a complication of rheumatoid arthritis (RA). Treatment with biological agents are clinically effective in particular, with their efficacy in suppressing joint destruction having been emphasized. However there is still no studies of efficacy of against RA cervical lesions of Tocilizumab (TCZ), anti-interleukin 6 receptor antibody. Objectives To evaluate the efficacy of TCZ for suppressing the radiographic progression of RA cervical lesions. Methods We used TCZ for treating 270 Japanese patients with active RA who fulfilled the ACR criteria in 1987. The final study cohort of 52 patients received continuous TCZ treatment for at least 1 year. For evaluation of cervical lesions, ADI, SAC and the Ranawat value were measured by plain lateral radiographs, at initiation and Week 52. Results The group of patients included 11 males and 41 females. The mean age was 53.4±12.9 years old; disease duration was 10.8±9.7 years; and the number of receiving methotrexate (MTX) was 37 (71%). Clinical findings related to RA were as follows; CRP, 3.7±2.6mg/dL; ESR, 56.1±27.0mm/h; DAS28 5.72±1.07; and CDAI, 24.7±12.7; ADI, 3.4±1.9mm; SAC, 18.9±2.7mm; Ranawat value, 14.9±2.7mm and TSS, 67.3±56.8. The numbers of patients who did not showed progression in ADI, SAC, Ranewat value and all three parameters were 37 (73%), 37 (73%), 39 (76%) and 36 (69%). In the naive (n=9) and switch patients (n=43), the respective changes in cervical lesion parameters in 1 year were as follows: ADI: 0.22±0.44 and 0.30±0.51 mm (p=0.707); SAC: −0.33±0.50 and −0.26±0.44 mm (p=0.637); and Ranawat value: −0.22±0.44 and −0.23±0.43 mm (p=0.947). In the patients of combination MTX (n=37) and non-combination MTX (n=15), the respective changes in cervical lesion parameters in 1 year were as follows: ADI: 0.32±0.53 and 0.20±0.41 mm (p=0.455); SAC: −0.24±0.44 and −0.33±0.49 mm (p=0.511); and Ranawat value: −0.22±0.42 and −0.27±0.46 mm (p=0.698). In the DAS remission (n=32) and non-remission patients (n=20), the respective changes in cervical lesion parameters in 1 year were as follows: ADI: 0.13±0.34 and 0.55±0.61 mm (p=0.003); SAC: −0.13±0.34 and −0.50±0.51 mm (p=0.003); and Ranawat value: −0.19±0.40 and −0.30±0.47 mm (p=0.354). On the other hand in the CDAI remission (n=14) and non-remission patients (n=38), the respective changes in cervical lesion parameters in 1 year were as follows: ADI: 0 and 0.40±0.55 mm (p=0.009); SAC: 0 and −0.37±0.49 mm (p=0.009); and Ranawat value: 0 and −0.32±0.47 mm (p=0.018). In the non-progressive (ΔTSS≤0, n=18) and progressive patients (ΔTSS >0, n=34), the respective changes in cervical lesion parameters in 1 year were as follows: ADI: 0 and 0.44±0.56 mm (p=0.002); SAC: 0 and −0.41±0.50 mm (p=0.002); and Ranawat value: 0 and −0.35±0.49 mm (p=0.004). Conclusions TCZ treatment can be used to suppress the progression of RA cervical lesions regardless of naïve or switch and with or without MTX. 1 year after initiation, the cervical lesion did not progress at all for the patients that a hand joint destruction did not progress and who achieved remission of the CDAI criteria at Week 52. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3741

FRI0282 Predictive Factors for Suppressing Progression of Cervical Lesions in Patients with Rheumatoid Arthritis Receiving Infliximab Treatment from Japanese Tbcr

Background Cervical lesions are known to occur at high frequency as a complication of rheumatoid arthritis (RA). Treatment with Anti-TNFα agents are more clinically effective than the DMARDs that were in use previously, in particular, with their efficacy in suppressing joint destruction having been emphasized. However, most clinical studies on the efficacy of biological agents in suppressing joint destruction in the hands and feet. Therefore, we reported the efficacy of infliximab (IFX) for suppressing the progression of RA cervical lesions at ACR2009, EULAR 2010, 11, 12 and 13. Objectives To investigate to determine predictive factors for suppressing radiographic progression of cervical lesions with RA receiving IFX treatment. Methods We used IFX for treating 604 Japanese patients with active RA who fulfilled the ACR criteria in 1987. The final study cohort of 67 patients received continuous IFX treatment for 3 years from Tsurumai Biologics Communication Registry (TBCR). For evaluation of cervical lesions, the atlanto-dental interval (ADI), the space available for the spinal cord (SAC), and the Ranawat value were measured by plain lateral radiographs in the flexion position, at initiation, 1, 2 and 3year. Results The group of patients included 9 males and 58 females. The mean age was 54.0±12.6 years; disease duration was 10.6±9.4 years; and methotrexate dose was 7.4±1.7 mg/week. Clinical findings related to RA were as follows: swollen and tender joint count, 7.0±5.2, 8.0±5.7; patients global assessment, 55.7±22.9mm; CRP, 3.4±2.0mg/dL; ESR, 53.4±29.2mm/h; DAS28 5.53±1.20; and MMP3, 363.4±331.3ng/mL; ADI, 3.5±1.7mm; SAC, 18.2±2.5mm; Ranawat value, 14.4±2.2mm and TSS, 60.9±51.4. When progression was defined as a change of 1 mm or more in one of the radiographic cervical lesion parameters for 3 years, the numbers of patients, who showed progression in ADI, SAC and Ranewat value were 25 (37%), 22 (33%), and 23 (34%), respectively, and the number who showed progression in at least one of these three parameters was 31 (46%). In order to determine predictive factors for suppressing progression of cervical lesions, We used Mann-Whitney U-test and ROC analysis between 36 non-progressive and 31 progressive patients. The factors which showed the significant difference were as follows: disease duration: 8.3±8.3 and 13.2±10.0 years (p=0.017); ADI: 3.0±1.4 and 4.0±2.0 mm (p=0.039); SAC 19.3±2.2 and 17.0±2.2 mm (p<0.001); Ranawat value: 15.1±1.5 and 13.6±2.6 mm (p=0.014); TSS at initiation: 49.3±50.0 and 74.3±50.3 mm (p=0.027); DAS at 3Y: 2.80±0.86 and 3.50±1.00 (p=0.002); average MMP3: 98.0±92.6 and 125.2±75.1 ng/ml (p=0.030); average DAS: 2.83±0.81 and 3.47±0.77 (p=0.001) and ΔTSS for 3 years: 0.68±0.71 and 1.73±1.04/y (p<0.001). The factors which showed the AUC0.7 were SAC at initiation, DAS at 3Y, average DAS for 3 years and ΔTSS (AUC=0.774, 0.721, 0.727 and 0.798). Also each cut-off value were 18.0, 2.70, 2.56 and 1.33 by Youden index method. Conclusions Early treatment, sustained remission and lower ΔTSS were important factors to suppress the progression of RA cervical lesions. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2685

OP0276 Efficacy of Daily Teriparatide for Two Years on Osteoporosis in Patients with Rheumatoid Arthritis – is IT Appropreate to Combine Daily Teriparatide and Biological Agents?

Background Although medication of rheumatoid arthritis (RA) has been improved by early intensive treatment using MTX and biological agents (BIO) for decades, treatment of concomitant disease in RA patients, such as osteoporosis (OP), will be more important to improve activity of daily living of RA patients. OP of RA patients is composed from multifactorial pathogenesis, such as excess of inflammatory cytokines, excess of rest due to joint pain and drugs used for treatment of RA. Although we reported one-year outcome of daily teriparatide (TPTD) on OP in RA patients in EULAR 2013 1), the additional results for 2 years are reported in this study. Objectives This prospective study investigated (1) the efficacy of TPTD for 2 years on OP in RA patients, (2) the predictors of efficacy at 2 year in TPTD treatment and (3) the outcome of combination of TPTD and BIO. Methods 24 months (m) passed after initiation of TPTD in 33 RA patents. 28 cases (27 females and a male) among them completed 2-year TPTD treatment and were used for analysis. Bone mineral density (BMD) of lumbar spine (LS) and proximal femur (PF) by DEXA and bone turnover markers (BTMs), that is BAP, P1NP, NTX and TRACP-5b, were measured at every 6m. Results Mean age was 72 years old. Mean RA duration was 20.2 years. 23 cases (69.7%) were concomitant with oral PSL. 14 cases (42.4%) were concomitant with BIO. 27 cases (81.8%) have the past history of fracture. %increase of LS-BMD was 6.9% at 6m, 11.2% at 12m, 11.8% at 18m and 12.5% at 24m. %increase of PF-BMD was 2.1% at 6m, 4.0% at 12m, 4.9% at 18m and 5.8% at 24m. BTMs were significantly increases and %increase of P1NP at 6m was maximum among them (384.0%). Next, all cases were divided into two group, good outcome group (GO group) and non-good outcome group (non-GO group), by mean LS-BMD and PF-BMD. %increase of LS-BMD at 6m in LS-GO group (n=14) was significantly larger than that in LS-non-GO group (n=12) (10.4% vs. 4.0%). %increase of PF-BMD at 6m in PF-GO group (n=14) was also significantly larger than that in LS-non-GO group (n=11) (4.7% vs. -1.1%). Baseline CRP in PF-non-GO group was also larger than that in PF-GO group (0.51mg/dl vs. 0.25mg/dl). There were no significant differences in changes of BTMs between groups. At last, all cases were divided into two groups, that is the BIO-concomitant (n=11) and the non-BIO-concomitant (n=17). LS-BMD in the non-BIO-concomitant was better than that in the BIO-concomitant and there was a significant difference between groups at 18m (7.8% vs. 14.0%). Similar findings were seen in analysis of PF-BMD and there was a significant difference between groups at 24m (3.6% vs. 7.4%). %increase of BTMs in the BIO-concomitant was high compared with that in the non-BIO-concomitant. Conclusions TPTD was effective in OP of RA patients. Early response in BMD was one of the predictors of outcomes at 24m. BTMs were not the predictors of efficacy of TPTD. The results in the BIO-concomitant showed different trend from that in whole cases and these paradoxical results suggested that medicinal action of TPTD might be interfere with that of BIO. References Y. Hirano et al. efficacy of teriparatide on osteoporosis in patients with rheumatoid arthritis. Ann Rheum Dis 2013;72(Suppl3):304. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2697

THU0411 Efficacy of Teriparatide on Osteoporosis in Patients with Rheumatoid Arthritis ~is it Appropriate to Prescribe Teriparatide Together with Biological Agents?

Background Although medication of rheumatoid arthritis (RA) has been improved by positive administration of methotrexate and biological agents (BIO) for decades, treatment of concomitant disease in RA patients, such as osteoporosis, will be more important for better outcome in RA patients. Osteoporosis of RA patients is composed from multifactorial pathogenesis, such as excess of inflammatory cytokines, excess of rest due to joint pain and drugs used for treatment of RA. Objectives This retrospective study investigated the efficacy of teriparatide (TPTD) on osteoporosis in RA patients and focused on relationship the efficacy of TPTD and concomitant drugs, such as oral prednisolone (PSL), activated vitamin D (actVitD) and BIO. Methods 45 cases (44 female and one male) were used in this study. Patients’ characteristics, bone mineral density (BMD) of lumbar spine (LS) and proximal femur (PF) measured by DEXA and bone turnover markers (BAP, P1NP, NTX, TRACP-5b) were investigated. (1)Factors that affect efficacy of TPTD, (2)the comparison between the BIO-concomitant and the non BIO-concomitant and (3)the comparison between the actVitD-concomitant and the non actVitD concomitant were analyzed. Results Mean age was 70.8 years old. Mean RA duration was 19.5 years. 31 case (68.9%) were concomitant with oral PSL. 15 cases (33.3%) were concomitant with BIO. 33 cases (73.3%) were concomitant with actVitD. 32 cases (71.1%) have the past history of fracture. %increase of LS-BMD in all cases was 7.6% at 6month and 11.9% at 12month. %increase of PF-BMD in all cases was 1.6% at 6month and 3.9% at 12month. Four bone turnover markers were significantly increased and %increase of P1NP was maximum among them. Significant low body mass index (BMI) and significant low oral PSL usage were seen in the good outcome group of LS-BMD. P1NP in good outcome group of LS-BMD was increased more than that in non good outcome group. Although %increase of BMD in the BIO-concomitant was low compared with that in the non BIO-concomitant, %increase of bone turnover markers in the BIO-concomitant was high compared with that in the non BIO-concomitant. This results was paradoxical from that in whole cases. %increase of PF-BMD in the actVitD-concomitant was better than that in the non actVitD-concomitant. Hypercalcemia occurred in 18.2% of the actVitD-concomitant and 8.3% of non actVitD concomitant (p=0.65). Conclusions TPTD was effective in osteoporosis of RA patients. Efficacy of TPTD in RA patients was affected with BMI, response of bone turnover markers and drugs concomitantly used. The results in the BIO-concomitant showed different trend from that in whole cases and these paradoxical results suggested that medicinal action of TPTD might be interfere with that of BIO. PF-BMD in the actVitD-concomitant was better than the non-concomitant and this result suggested that some patients needed actVitD when treated with TPTD. Disclosure of Interest None Declared

AB0339 A retrospective study on rapidness of efficacy in abatacept terapy in patients with rheumatoid arthritis from japanese multicenter registry system

Background Abatacept (ABT) is an effective biological agent which has unique mechanism to reduce disease activity of rheumatoid arthritis (RA). Although good continuation rate and safety in ABT treatment was reported, ABT treatment has a tendency that response of drug was relatively delayed, what we call the slow starter [1, 2]. However, rapid effectiveness with ABT treatment is seen in some RA patients in clinical setting and the factors influencing the rapidness of effectiveness of ABT treatment have not been well understood. Objectives The objectives of this retrospective study is to analyze the patients’ characteristics of RA patients treated with ABT with rapid effectiveness using Japanese multicenter registry system (TBC). Methods A Japanese multicenter registry database for biological treatment in RA patients (TBC) was used in this study. This study utilized RA patients who continued ABT for 24 weeks and in whom disease activity score 28 using CRP (DAS28-CRP) was over 3.2 at initiation of ABT and below 3.2 at 24 weeks (responders). Patients in whom early improvement rate of DAS28 (=delta DAS28 from 0w to 4w/delta DAS28 from 0w to 24w) was over 0.5 were called rapid effectiveness group (RG, n=35) and patients in whom early improvement rate was below 0.5 were called slow effectiveness group (SG, n=38). Patients’ characteristics at baseline were compared between two groups. Results Mean DAS28 were 4.69(0w), 3.03(4w), 2.79(12w), 2.43(24w) in RG and 4.58(0w), 4.10(4w), 3.24(12w), 2.45(24w) in SG. There was a significant difference between two groups at 4w and 12w. There were no significant differences between two groups in age, RA duration, rheumatoid factor level and baseline disease activity evaluated using DAS28, SDAI, CDAI, CRP, ESR and MMP-3. The rate of bio-naive which meant ABT was first biologics was 77.1% (27 cases) in RG and 55.3% (21 cases) in SG (p=0.049). Mean serum immune globulin G (IgG) value at initiation of ABT was 1731mg/dl in RG and 1420mg/dl in SG (p=0.078). The rate of concomitant methotrexate (MTX) was 62.9% (22 cases) in RG and 39.5% (15 cases) in SG. Conclusions This study suggests that previous biologics treatment may affects immunological condition in patients with RA and that may result in the differences in effectiveness speed of ABT. This study also showed that serum IgG level at baseline was one of the predictive factors of rapid effectiveness in ABT treatment. Although IgG is secreted from B-lymphocytes (B-cells), function of B-cells is influenced by the activity of T-lymphocytes (T-cells). Serum IgG shows the activity of T-cells indirectly and effectiveness in ABT treatment may be rapid in RA patients with increased actuvity of T-cells compared with in patients with decreased activity of T-cells. References Sciff M et al. Efficacy and safety of abatacept or infliximab vs placebo in ATTEST: a phase III, multicentre, randomized, double-blind, placebo-controlled study in patients with rheumatoid arthritis and an inadequate response to methotrexate. Ann Rheum Dis. 2008; 67: 1096-1103. Singh JA et al. Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database Disclosure of Interest None Declared