Comparative Effectiveness of Treatments for Rheumatoid Arthritis

Rheumatoid arthritis is a chronic autoimmune disease of uncertain cause associated with symmetric polyarthritis and, in some patients, with extra-articular manifestations. Patients with rheumatoid arthritis experience a chronic, fluctuating course that may result in joint damage, disability, deformities, and even a shortened life span. The goals of treatment are to control pain and inflammation and to avoid, to the extent possible, progressive joint destruction.

In recent years, studies comparing immediate with delayed treatment with disease-modifying antirheumatic drugs (DMARDs) have shown that early treatment with these drugs is associated with improved outcomes for signs and symptoms and slower progression of damage to joints (1). Currently available DMARDs fall into 2 broad categories: synthetic DMARDs, including sulfasalazine, hydroxychloroquine, methotrexate, and leflunomide, and biological DMARDs, including tumor necrosis factor–blocking agents, anakinra, abatacept, and rituximab. Pharmacologic treatment for patients with rheumatoid arthritis typically consists of synthetic DMARDs, alone or in combination, or a biological DMARD, either alone or in combination with 1 or more synthetic DMARDs. Biological DMARDs are not generally used in combination with other biological DMARDs because several of these combinations have shown increased toxicity (2, 3).

Given the multiplicity of effective DMARDs, clinicians need an up-to-date, comprehensive summary of the evidence to help them choose 1 DMARD over another for …