Review: adding newer disease-modifying drugs or biological agents to methotrexate improved rheumatoid arthritis symptoms.

In patients with rheumatoid arthritis (RA) and an incomplete response to methotrex-ate, does the addition of biological agents or newer, disease-modifying antirheumatic drugs (DMARDs) to methotrexate prompt a more complete response than does the addition of placebo? D a t a s o u r c e s An existing systematic review was updated. Additional studies were identified by searching MEDLINE (July 1997 to December 2000) with the terms rheumatoid arthritis and combination drug therapy, bibliographies of relevant studies, and abstracts of scientific presentations of the American College of Rheumatology (ACR) from 1998 to 2000 and by contacting authors of studies that used a step-up strategy in patients with RA. Studies were selected if they were random-ized, double-blind, placebo-controlled trials that added therapeutic agents to methotrex-ate in patients with active RA. D a t a e x t r a c t i o n Data were extracted on patient characteristics (age, sex, race, duration of RA, proportion who were rheumatoid-factor positive), con-comitant treatment, study drug and methotrexate dose and duration, eligibility criteria, baseline disease activity, and outcome measures. The primary outcome was ACR 20 response (i.e., improvement of ≥ 20% in swollen and tender joint counts in 3 of 5 ACR end points [pain, patient global assessment , physician global assessment, disability score, and erythrocyte sedimentation rate]). 4 trials were included (928 patients). The active treatments (in addition to methotrex-ate) were cyclosporin, 2.5 mg/kg of body weight per day; etanercept, 25 mg twice weekly; infliximab, 3 mg/kg every 4 or 8 weeks or 10 mg/kg every 4 or 8 weeks; and leflunomide, 100 mg/d for 2 days, then 10 mg/d. Treatment duration ranged from 24 to 30 weeks. Each of the 4 active treatments was more effective than placebo. No evidence of heterogeneity existed among the trials, and the 95% CIs for the relative risks of the individual trials overlapped (Table). In patients with rheumatoid arthritis and an incomplete response to methotrexate, the addition of cyclosporin, etanercept, inflix-imab, or leflunomide led to an American College of Rheumatology 20 response in 2 to 3 times as many patients as did the addition of placebo. 97 C o m m e n t a r y The advent of biological agents (in particular the antitumor necrosis factor agents infliximab and etanercept) has rightly been hailed as a major breakthrough in the treatment of RA, especially in patients whose RA is resistant …