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Drug Therapy for Rheumatoid Arthritis in Adults: An Update [Internet]

Drug Therapy for Rheumatoid Arthritis in Adults: An Update [Internet]

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US)

Version: April 2012


This report provides a comprehensive review of the comparative efficacy, effectiveness, and harms of members of the main classes of drugs used to treat adult patients with rheumatoid arthritis (RA). These include oral disease-modifying antirheumatic drugs (DMARDs), and biologic DMARDs. The objective of our report was to evaluate the comparative efficacy, effectiveness, and harms of monotherapies, combination therapies, and different treatment strategies.

Executive Summary

Rheumatoid arthritis (RA), which affects 1.3 million adult Americans, is an autoimmune disease that involves inflammation of the synovium (a thin layer of tissue lining a joint space) with progressive erosion of bone leading in most cases to misalignment of the joint, loss of function, and disability. The disease tends to affect the small joints of the hands and feet in a symmetric pattern, but other joint patterns are often seen. The diagnosis is based primarily on the clinical history and physical examination with support from selected laboratory tests. Treatment of patients with RA aims to control pain and inflammation and, ultimately, the goal is remission or at least low disease activity for all patients. Available therapies for RA include corticosteroids, oral disease-modifying antirheumatic drugs or DMARDs (hydroxychloroquine, leflunomide, methotrexate [MTX], and sulfasalazine), and biologic DMARDs (five anti-tumor necrosis factor drugs [anti-TNF]: adalimumab, certolizumab, etanercept, golimumab, infliximab; and others including abatacept, anakinra, rituximab, and tocilizumab).


Figure 1 depicts the disposition of identified articles. We included 258 published articles reporting on 211 studies: 31 head-to-head randomized controlled trials (RCTs), 1 head-to-head nonrandomized controlled trial, 44 placebo-controlled trials, 28 meta-analyses or systematic reviews, and 107 observational studies. Our findings include studies rated good or fair for internal validity, unless a particular study rated poor provides some unique information that we judged to be of interest. Most studies were of fair quality; we designate in the text only those of good or poor quality. Evidence tables for included studies, by Key Question (KQ), can be found in Appendix E.


Arthritis and other rheumatic conditions constitute the leading cause of disability among U.S. adults, with more than 46 million Americans reporting doctor-diagnosed arthritis. Noninflammatory arthritic conditions (e.g., osteoarthritis) are most common, but inflammatory arthritides such as spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis [PsA]), and reactive arthritis) and rheumatoid arthritis (RA) can be equally or more disabling.


In this chapter, we document the procedures that the RTI International–University of North Carolina Evidence-based Practice Center (RTI–UNC EPC) used to develop this comparative effectiveness review (CER) on pharmacologic treatments for rheumatoid arthritis. We briefly describe the topic development process below. We then document our literature search and retrieval process and describe methods of abstracting relevant information from the eligible articles to generate evidence tables. We also document our criteria for rating the quality of individual studies and for grading the strength of the evidence as a whole.

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