Comparative Efficacy of Different Biologic Agents on Radiographic Progression in Patients with Rheumatoid Arthritis: A Network Meta-Analysis.

Abstract

Radiographic progression in rheumatoid arthritis (RA) reflects irreversible joint damage. Whether different classes of biologic disease-modifying antirheumatic drugs (bDMARDs) offer comparable structural protection remains uncertain. To compare six bDMARD classes (tumor necrosis factor [TNF]-α inhibitors, interleukin [IL]-17 inhibitors, T-cell co-stimulation modulators, B-cell depleting agents, IL-6 receptor antagonists, and IL-23 inhibitors) in suppressing radiographic progression in RA. PubMed, Embase, Web of Science, and CENTRAL were searched to 31 December 2025 for randomized controlled trials (RCT); change in modified Total Sharp Score (mTSS) at 12 months was the primary outcome. A Bayesian random-effects network meta-analysis was fitted, with SUCRA-based ranking. 27 RCTs (11,650 patients) were included. All six classes significantly inhibited mTSS progression versus placebo. Relative to TNF-α inhibitors (TNF-i), greater inhibition was seen with B-cell depleting agents (mean difference [MD] = -18.46, 95% CI -20.86 to -16.06), IL-23 inhibitors (MD = -18.14, 95% CI -21.11 to -15.16), IL-17 inhibitors (MD = -15.67), T-cell co-stimulation modulators (MD = -14.99) and IL-6 receptor antagonists (MD = -13.73); the first two were also superior to IL-6 receptor antagonists. For bone erosion (13 RCTs), IL-17, B-cell depleting, IL-6 receptor and T-cell agents, but not IL-23 inhibitors, were superior to TNF-i. For ACR20 (20 RCTs), IL-23 (OR = 2.75, 95% CI 1.31-5.76), IL-6 (OR = 2.12) and IL-17 (OR = 1.86) inhibitors were superior to TNF-i. Serious adverse events (10 RCTs) did not differ from placebo. B-cell depleting agents and IL-23 inhibitors ranked highest; as several comparisons rest on few trials, this ordering is hypothesis generating.