REVIEW - Systematic review: comparative effectiveness and harms of DMARDs for RA

[Guest guest]

Ann Intern Med. 2008 Jan 15;148(2):124-34. Epub 2007 Nov 19.

Comment in:

Ann Intern Med. 2008 Jan 15;148(2):162-3.

Systematic review: comparative effectiveness and harms of

disease-modifying medications for rheumatoid arthritis.

Donahue KE, Gartlehner G, Jonas DE, Lux LJ, Thieda P, Jonas BL, Hansen

RA, LC, Lohr KN.

University of North Carolina and Cecil G. Sheps Center for Health

Services Research, Chapel Hill, North Carolina 27599, USA.

BACKGROUND: The comparative effectiveness of rheumatoid arthritis

therapies is uncertain. PURPOSE: To compare the benefits and harms of

disease-modifying antirheumatic drugs (DMARDs) for adults with

rheumatoid arthritis. DATA SOURCES: Records limited to the English

language and studies of adults were identified by using MEDLINE,

EMBASE, The Cochrane Library, and International Pharmaceutical

Abstracts from 1980 to September 2007. STUDY SELECTION: Two persons

independently selected relevant head-to-head trials and prospective

cohort studies with at least 100 participants and 12-week follow-up

and relevant good- or fair-quality meta-analyses that compared

benefits or harms of 11 drug therapies. For harms, they included

retrospective cohort studies. DATA EXTRACTION: Information on study

design, interventions, outcomes, and quality were extracted according

to a standard protocol. DATA SYNTHESIS: Head-to-head trials (n = 23),

mostly examining synthetic DMARDs, showed no clinically important

differences in efficacy among synthetic DMARDs (limited to

methotrexate, leflunomide, and sulfasalazine) or among anti-tumor

necrosis factor drugs (adalimumab, etanercept, and infliximab).

Monotherapy with anti-tumor necrosis factor drugs resulted in better

radiographic outcomes than did methotrexate but no important

differences in clinical outcomes (for example, 20%, 50%, or 70%

improvement according to American College of Rheumatology response

criteria). Various combinations of biological DMARDs plus methotrexate

improved clinical response rates and functional outcomes more than

monotherapy with either methotrexate or biological DMARDs. In patients

whose monotherapy failed, combination therapy with synthetic DMARDs

improved response rates. Numbers and types of short-term adverse

events were similar for biological and synthetic DMARDs. The evidence

was insufficient to draw conclusions about differences for rare but

serious adverse events for biological DMARDs. LIMITATION: Most studies

were short-term efficacy trials conducted in selected populations with

few comorbid conditions.

CONCLUSION: Limited available comparative evidence does not support

one monotherapy over another for adults with rheumatoid arthritis.

Although combination therapy is more effective for patients whose

monotherapy fails, the evidence is insufficient to draw firm

conclusions about whether one combination or treatment strategy is

better than another or is the best treatment for early rheumatoid

arthritis.

PMID: 18025440

http://www.ncbi.nlm.nih.gov/pubmed/18025440

--

Not an MD