REVIEW - Comparative effectiveness and harms of DMARDs for RA

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ls of Internal Medicine

15 January 2008 | Volume 148 Issue 2 | Pages 124-134

Systematic Review: Comparative Effectiveness and Harms of

Disease-Modifying Medications for Rheumatoid Arthritis

Katrina E. Donahue, MD, MPH; Gerald Gartlehner, MD, MPH; E.

Jonas, MD, MPH; J. Lux, MPA; Thieda, MA; Beth L. Jonas,

MD; A. Hansen, PhD; C. , MA; and Kathleen N. Lohr,

PhD

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.

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Read the full article here:

http://annals.highwire.org/cgi/content/full/148/2/124

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