REVIEW - Current evidence for the management of RA with synthetic DMARDs

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Ann Rheum Dis. 2010 May 6. [Epub ahead of print]

Current evidence for the management of rheumatoid arthritis with

synthetic disease-modifying antirheumatic drugs: a systematic

literature review informing the EULAR recommendations for the

management of rheumatoid arthritis.

Gaujoux-Viala C, Smolen JS, Landewé R, Dougados M, Kvien TK, Mola EM,

Scholte-Voshaar M, van Riel P, Gossec L.

1Pierre et Marie Curie University-Paris VI, APHP, Rheumatology,

Pitié-Salpétrière Hospital, Paris, France.

Abstract

OBJECTIVES: To assess the efficacy and safety of synthetic

disease-modifying antirheumatic drugs (DMARDs) in adults with

rheumatoid arthritis (RA)-a first step in a European League Against

Rheumatism (EULAR) initiative to produce recommendations for the

management of RA.

METHODS: A systematic review of the literature using PubMed, Embase

and the Cochrane library was performed up to January 2009. All

randomised controlled trials (RCTs) reporting the efficacy of

synthetic DMARDs (vs placebo or other synthetic DMARDs) on signs and

symptoms, disability and/or radiographic structural damage in patients

with RA were selected. Studies of biological agents or glucocorticoids

were excluded. A pooled effect size (ES) was calculated by

meta-analysis. Safety and the occurrence of infections and neoplasia

was also assessed.

RESULTS: 97 RCTs (14 159 patients) were analysed for efficacy. The

pooled analysis indicated that methotrexate (MTX) was more efficacious

in reducing signs and symptoms, disability and radiographic structural

damage than other synthetic DMARDs pooled: ES for swollen joint count

(SJC) versus pooled DMARDs=1.42 (95% CI 0.65 to 2.18). Leflunomide

appeared to be as effective as MTX. Sulfasalazine and injectable gold

were efficacious in reducing signs and symptoms and structural damage.

Ciclosporin, minocycline, tacrolimus and hydroxychloroquine showed

some efficacy in reducing SJC. Auranofin and D-penicillamine showed no

significant superiority over placebo. The risks of cancer and of

infection were increased with cyclophosphamide and azathioprine.

CONCLUSIONS: MTX was well-tolerated and effective in reducing signs

and symptoms, disability and structural damage. A comparison with

other synthetic DMARDs was in favour of MTX, though at the tested

doses MTX and leflunomide were equally effective.

PMID: 20447954

http://www.ncbi.nlm.nih.gov/pubmed/20447954

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