Stairway to Heaven: Do head-to-head Trials Indicate a Need for Definite Criteria for Choosing Biologic Drugs in Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic disease characterized by joint and systemic involvement that develops with different pathogenetic mechanisms. Treatment of the disease is undertaken with disease-modifying anti-rheumatic drugs (DMARDs). The mechanisms of action of conventional DMARDs generally are based on the inhibition of T and B-cells in the immune system. In recent years, biologic and targeted smart molecules have been used in the treatment of RA. Targeting different cytokines and inflammatory pathways, these drugs have ushered in a new era in RA treatment. The efficacy of these drugs has been demonstrated in many studies; and in the post-marketing period, that is, as the patients who use them say, they are like a "stairway to heaven". However, as every "road to heaven" is challenging and "thorny", the efficacy and reliability of these drugs and whether any one of them is superior to the others, remains a matter of debate. However, the use of biologic drugs with or without cDMARDs, the preference for original vs. biosimilar molecules, and discontinuation of the drugs after achieving sustained remission are other questions that need to be explored. When it comes to the choice of biological drugs by rheumatologists, it is not yet clear on which criteria they base their choices on. Due to the limited comparative studies of these biological drugs, the subjective criteria of the physician gains importance. The selection of these drugs, however, should be based on objective criteria such as efficacy, safety, superiority over each other, and cost. In other words, the determinant of the "path to heaven" should be based on objective criteria and recommendations according to the scientific data generated by controlled-prospective studies, not on the initiative of a single physician. In this review, a head-to-head comparison of biological drugs used in the treatment of RA, their efficacy, safety, and which are superior are discussed in light of recent literature data.