Efficacy of Glucocorticoids, Conventional and Targeted Synthetic Disease-Modifying Antirheumatic Drugs: A Systematic Literature Review Informing the 2016 Update of the EULAR Recommendations for the Management of Rheumatoid Arthritis

Ann Rheum Dis. 2017 Jun;76(6):1102-1107. doi: 10.1136/annrheumdis-2016-210711. Epub 2017 Mar 29.

Abstract

Objectives: To perform a systematic literature review (SLR) informing the 2016 update of the recommendations for the management of rheumatoid arthritis (RA).

Methods: An SLR for the period between 2013 and 2016 was undertaken to assess the efficacy of glucocorticoids (GCs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and targeted synthetic DMARDs (tsDMARDs) (tofacitinib and baricitinib) in randomised clinical trials.

Results: For GCs, four studies were included in the SLR. Patients without poor prognostic factors experienced benefit when GCs were added to methotrexate (MTX). Lower doses of GCs were similar to higher doses. For csDMARDs, two new studies comparing MTX monotherapy with combination csDMARD were included in the SLR. In the tREACH trial at the end of 12 months no difference between the groups in disease activity, functional ability and radiographic progression was seen, using principles of tight control (treat-to-target). In the CareRA trial, combination therapy with csDMARDs was not superior to MTX monotherapy and monotherapy was better tolerated.For tsDMARDs, tofacitinib and baricitinib were shown to be more effective than placebo (MTX) in different patient populations.

Conclusions: Addition of GCs to csDMARD therapy may be beneficial but the benefits should be balanced against the risk of toxicity. Under tight control conditions MTX monotherapy is not less effective than combination csDMARDs, but better tolerated. Tofacitinib and baricitinib are efficacious in patients with RA, including those with refractory disease.

Keywords: Corticosteroids; DMARDs (synthetic); Rheumatoid Arthritis; Treatment.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Antirheumatic Agents / therapeutic use*
  • Arthritis, Rheumatoid / drug therapy*
  • Azetidines / therapeutic use
  • Drug Therapy, Combination
  • Glucocorticoids / therapeutic use
  • Humans
  • Methotrexate / therapeutic use
  • Piperidines / therapeutic use
  • Practice Guidelines as Topic
  • Pyrimidines / therapeutic use
  • Pyrroles / therapeutic use
  • Randomized Controlled Trials as Topic
  • Sulfonamides / therapeutic use

Substances

  • Antirheumatic Agents
  • Azetidines
  • Glucocorticoids
  • Piperidines
  • Pyrimidines
  • Pyrroles
  • Sulfonamides
  • tofacitinib
  • baricitinib
  • Methotrexate