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Do all drugs and treatments for rheumatoid arthritis have the same efficacy?

Nature Clinical Practice Rheumatology volume 4, pages 298–299 (2008)Cite this article

Following a well-established standardized process, health service researchers from the University of North Carolina recently performed a systematic review to compare the benefits and harms of disease-modifying anti-rheumatic drugs (DMARDs) for adults with rheumatoid arthritis (RA).1 Beginning with 2,395 titles and abstracts, they reduced the list to 143 articles, the majority of which were either head-to-head randomized controlled trials (n = 42) or observational cohort studies (n = 58). The authors concluded that the “scant” head-to-head evidence did not reveal clinically important differences between synthetic DMARDs. Anti-tumor necrosis factor (TNF) agents were associated with better radiological outcomes than was methotrexate, but no important clinical differences were reported. Various combinations of anti-TNF agents plus methotrexate produced better outcomes than either agent alone, but there was insufficient evidence to draw any conclusions about differences in risk of harm, except that substantially increased rates of serious adverse events were seen with combination biologic agent therapy. On the basis of the data reviewed, the authors were unable to state that one combination or treatment strategy outweighed any other, or was indicated for early RA or any specific subgroup of patients with RA. There is, however, other evidence for a different set of conclusions.

Given the methodologies employed for the analysis, the conclusions could easily have been predicted. But should we be satisfied? The authors clearly state, as a limitation of the review, that most of their findings stem from short-term efficacy trials. Trials sponsored by pharmaceutical companies are largely conducted for registration purposes, and are typically designed to achieve the desired result using highly selective patient recruitment processes, which are often based on a previous study of a competitor drug in order to show similarities in short-term efficacy. Long-term results from open-label trials are often published later, but their purposes are not always clear, except perhaps to keep the names of the drug, the company, and the investigators in the public eye. Given these caveats, it is not surprising that few differences between therapies are seen on the basis of these studies.

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  1. Division of Rheumatology, Cedars–Sinai Medical Center, 8700 Beverly Boulevard, Becker B-131, Los Angeles, CA 90048, USA michael.weisman@cshs.org

Authors and Affiliations

  1. MH Weisman is the Director of the Division of Rheumatology, Cedars–Sinai Medical Center, Los Angeles, CA, USA.,

    Michael H Weisman

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Competing interests

MH Weisman has received research grants from the following companies: Abbott, Amgen, Bristol-Myers Squibb, Centocor, Genentech, Human Genome Sciences, UCB, Wyeth and XDx Expression Diagnostics. MH Weisman is a consultant/advisor/member of Data-Safety Monitoring Board for the following companies: Abbott, Amgen, Array, Biogen, Centocor, Elan, Genentech, Human Genome Sciences, Merck, TAP, UCB and Wyeth.

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Weisman, M. Do all drugs and treatments for rheumatoid arthritis have the same efficacy?. Nat Rev Rheumatol 4, 298–299 (2008). https://doi.org/10.1038/ncprheum0806

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