A new literature review updated the information on the effectiveness and safety of different classes of treatment strategies for rheumatoid arthritis (RA).
The study, “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,” appeared in the journal Annals of the Rheumatic Diseases.
Earlier diagnosis and treatment with well-defined goals have contributed to significant changes in RA treatment. And the development and introduction of disease-modifying antirheumatic drugs (DMARDs) have added to this treatment revolution.
Despite this progress, better treatment strategies are needed. Clinicians would benefit from practical recommendations based on the latest evidence, which would help achieve a better application of the available treatments.
A research team led by Katerina Chatzidionysiou, MD, PhD, from the Karolinska Institute in Sweden performed a systematic literature review of the 2016 update on the 2013 European League Against Rheumatism (EULAR) recommendations for the management of RA.
The researchers reviewed data between 2013 and 2016 to assess the effectiveness of glucocorticoids (GCs), conventional synthetic DMARDs (csDMARDs), and targeted synthetic DMARDs (tsDMARDs) — Xeljanz (tofacitinib) and Olumiant (baricitinib) — in randomized clinical trials in adult RA patients. The data was compared with that of patients not receiving the above treatments.
Analyses of four studies revealed that the addition of GCs to standard methotrexate (MTX) therapy leads to clinical benefits in patients without poor prognostic factors. In addition, the combination of GCs with csDMARDs led to a reduction in disease activity and improved health-related quality of life in patients with established RA.
The scientists also analyzed two studies comparing MTX as a single therapy with MTX in combination with csDMARDs. In the tREACH trial, no difference between the groups in disease activity, functional ability and radiographic progression was seen after 12 months. The rate of adverse effects was greater in the combination group, however.
And, in the CareRA clinical trial in patients with early RA and risk factors for more aggressive disease, a combination therapy of MTX with csDMARDs was not superior to MTX monotherapy, which was better tolerated.
Regarding tsDMARDs, Xeljanz and Olumiant, both as monotherapies and in combination with MTX, were shown to be more effective than MTX alone in improving disease activity and physical function in different patient populations. However, in the case of Olumiant, only the combination with MTX significantly inhibited radiographic progression. Of note, treatment with Xeljanz was associated with an increased risk of herpes infection.
Overall, this review shows that although “efficacy of short-term GCs when added to csDMARDs is robust and undisputed, there are still concerns regarding long-term safety.” Furthermore, “in contradiction with the perception of many clinicians,” MTX monotherapy is better tolerated and not less effective than combination csDMARDs. This review also highlights the need for studies evaluating the optimal use of csDMARDs, including treatment doses.
Finally, the study also shows that Xeljanz and Olumiant are effective treatments in patients with RA, including those with refractory disease. But the authors state that “data on long-term safety of this new class of DMARDs from real life observational studies are needed.”