DMARDs, Glucocorticoids, and Biologics May Be Equally Effective for Rheumatoid Arthritis

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Date Posted : 2010-10-13

October 1, 2010 — Disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, and biologics appear to have similar effects on radiographic progression in rheumatoid arthritis (RA), according to the results of a meta-analysis reported in the October issue of Arthritis & Rheumatism.

"During the last 10 years, several effective, but expensive immuno-selective biologic drugs (biologics) have been introduced in the treatment of ...RA," write Niels Graudal, MD, DrMedSci, from Copenhagen University Hospital, Rigshospitalet, in Denmark, and Gesche Jürgens, MD, PhD, from Bispebjerg University Hospital, also in Denmark.

"The biologics are currently used as second-line drugs, but in clinical trials they have been used to treat DMARD naive patients, and some guidelines recommend biologics as first treatment to selected patients with suspected poor prognosis. ...The purpose of this treatment review of ...RA was to define the differences in effects on joint destruction between ...DMARD single- and combination therapy, glucocorticoid therapy and biologic therapy."

Using Review Manager 5.0 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the investigators performed 21 meta-analyses summarizing data from 70 randomized placebo-controlled or drug- controlled studies including 112 comparisons and 16 interventions. Trials were included that assessed the effect of drug treatment on the percentage of the annual radiographic progression rate (PARPR).

In this meta-analysis, the investigators compared 5 main treatment groups:

•Group 1: single DMARD vs a single DMARD.
•Group 2: single DMARD vs placebo or analogue.
•Group 3: combination of DMARDs vs a single DMARD.
•Group 4: glucocorticoid (plus or minus a DMARD) vs placebo (plus or minus a DMARD).
•Group 5: biologic interventions vs different controls (eg, methotrexate).
In the single-DMARD group, the PARPR was 0.90% smaller vs the placebo group (P < .00001), and PARPR was 0.54% smaller in the glucocorticoid group vs the placebo group (P < .00001). PARPR was 0.80% smaller in the DMARD combination group (P < .001) and 0.63% smaller in the biologic plus methotrexate group (P < .00001) vs the group receiving treatment with a single DMARD. Effects were similar for a combination of 2 DMARDs plus step-down glucocorticoids vs a biologic plus methotrexate (–0.07%; 95% confidence interval –0.25 to 0.11; P = .44).

"DMARDs, glucocorticoids, biologics and combination treatments significantly reduced radiographic progression at one year with a relative effect of 50-80%," the study authors write. "A direct comparison between a combination of biologic + MTX [methotrexate] and a double DMARD combination + initial glucocorticoid revealed no difference. Consequently, biologics should still be reserved for DMARD resistant patients."

Limitations of this meta-analysis include limited number of studies for each treatment comparison.

Due to various biases it was found improper to rank the individual DMARDs and the individual biologics," the study authors conclude. "Consequently, we do not believe that the necessary evidence exists to judge which individual treatment is preferable.... In the future, trials of the effect of biologics on RA should be compared with combination treatments involving DMARDs and glucocorticoids

The A. P. Møller Foundation for the Advancement of Medical Science supported this study. The study authors have disclosed no relevant financial relationships.

Arthr Rheum. 2010;62:2852-2863.
From MedscapeCME Clinical Briefs

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