Intra-articular therapy with methotrexate or tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic review

BMC Musculoskelet Disord. 2021 Sep 15;22(1):792. doi: 10.1186/s12891-021-04651-5.

Abstract

Background: Persistent monoarthritis in otherwise well-controlled rheumatoid arthritis presents a therapeutic challenge. Intra-articular (IA) steroids are a mainstay of treatment, though some have queried whether IA disease modifying anti-rheumatic drugs (DMARD) and biologics can be used in those who fail steroid injections.

Methods: A systematic literature review was conducted using four medical databases to identify randomized, controlled trials assessing IA therapies in RA patients. Included studies underwent Cochrane Risk of Bias 2 assessment for quality.

Results: Twelve studies were included, 6 of which examined intra-articular (IA) TNF inhibitors (TNFi), and 6 studies evaluating IA methotrexate. Of those evaluating IA TNFi, one study reported statistical improvement in TNFi therapy when compared with placebo. The remaining 5 studies compared IA TNFi therapy with steroid injections. IA TNFi had statistically improved symptom scores and clinical assessments comparable with IA steroid treatments. In the 6 studies evaluating IA methotrexate, the addition of methotrexate to steroid intra-articular therapy was not found to be beneficial, and singular methotrexate injection was not superior to the control arms (saline or triamcinolone). Risk-of-bias (ROB) assessment with the Revised Cochrane ROB tool indicated that 2 of 6 TNFi studies were at some risk or high risk for bias, compared with 5 out of 6 methotrexate studies.

Conclusion: For persistent monoarthritis in rheumatoid arthritis, IA methotrexate was not found to have clinical utility. Intra-articular TNFi therapy appears to have equal efficacy to IA steroids, though the optimal dose and frequency of injections is yet unknown.

Keywords: Corticosteroid; Injection; Intraarticular; Joint; Methotrexate; Monoarthritis; Review; Rheumatoid arthritis; Tumor necrosis factor inhibitor.

Publication types

  • Systematic Review

MeSH terms

  • Antirheumatic Agents* / adverse effects
  • Arthritis, Rheumatoid* / diagnosis
  • Arthritis, Rheumatoid* / drug therapy
  • Biological Products* / adverse effects
  • Humans
  • Methotrexate / therapeutic use
  • Treatment Outcome
  • Tumor Necrosis Factor Inhibitors
  • Tumor Necrosis Factor-alpha

Substances

  • Antirheumatic Agents
  • Biological Products
  • Tumor Necrosis Factor Inhibitors
  • Tumor Necrosis Factor-alpha
  • Methotrexate