View Systematic Review Update Report

Rheumatoid arthritis (RA), an autoimmune systemic inflammatory arthritis condition, affects more than 1 million American adults. The onset of RA can begin at any age but increases with age; onset is highest at 60 years. Incidence of RA is 2 to 3 times higher in women. RA causes inflammation of the synovial lining of joints, leads to progressive erosion of bone (in most cases to irreversible damage to the joint), loss of function, and disability. In patients newly diagnosed with RA (early RA), the goal is early treatment with rapid, sustained remission. Treatment of RA aims to control pain and inflammation and, ultimately, to slow the progression of joint destruction and disability. Available disease-modifying antirheumatic drug (DMARD) therapies for RA include corticosteroids, conventional synthetic DMARDs (csDMARDs), tumor necrosis factor (TNF) and non-TNF biologics, targeted synthetic DMARDs (tsDMARDs), and biosimilars. Challenges and controversies related to RA include

1. Definition of early disease,
2. The appropriate use and order or combination of different therapeutic options,
3. Optimal approach to managing RA therapy in the setting of coexisting conditions (malignancy, infections, pregnancy), and
4. The role of newly approved drugs in the treatment strategies in the context of older medications.

This systematic review (SR) and meta-analysis updates a 2012 report published by the Agency for Healthcare Research and Quality’s Effective Healthcare Program, but with a targeted scope focusing solely on patients with early RA. The key questions (KQs) for this systematic review update derive from the original review and have been updated based on stakeholder feedback obtained by PCORI. The key questions are:

1. For patients with early RA, do drug therapies differ in their ability to reduce disease activity, slow or limit the progression of radiographic joint damage, or induce remission?
2. For patients with early RA, do drug therapies differ in their ability to improve patient-reported symptoms, functional capacity, or quality of life?
3. For patients with early RA, do drug therapies differ in harms, tolerability, patient adherence, or adverse effects?
4. What are the comparative benefits and harms of drug therapies for early RA in subgroups of patients based on disease activity, prior therapy, demographics (e.g., women in their childbearing years), concomitant therapies, and presence of other serious conditions?

The review also asks 2 contextual questions, which are not systematically reviewed but use a "best evidence" approach:

1. Does treatment of early RA improve disease trajectory and disease outcomes compared with the trajectory or outcomes of treatment of established RA?; and
2. What barriers prevent individuals with early RA from obtaining access to indicated drug therapies?

More on This Project

• Final Protocol for This Review
• Stakeholder Workshop
• AHRQ Project Page
• View Systematic Review Update Report (Published June 2018)