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Strengths and limitations of a systematic review on DMARDs for rheumatoid arthritis

Nature Clinical Practice Rheumatology volume 4, pages 296–297 (2008)Cite this article

Systematic reviews are generally important contributions to the literature. Performing a comprehensive evaluation of published clinical trials in a disease such as rheumatoid arthritis (RA) is a particular challenge, given the heterogeneity of the populations enrolled and the approaches to treatment, the many novel therapies studied over the past dozen years, the absence of clinical trials comparing some of the older treatment options, and the possibility of arriving at differing conclusions depending on the interpretative point of view one takes.

A review by Donahue et al.1 of trials examining synthetic and biologic disease modifying anti-rheumatic drugs (DMARDs) provides the following conclusive information: no synthetic DMARD or tumor necrosis factor (TNF)-inhibitor has been shown clinically to be more efficacious than any other monotherapy, although biologic agents appear to retard joint damage more effectively than synthetic DMARDs; combination therapy with synthetic DMARDs is effective in patients who have active disease despite initial treatment with DMARD monotherapy ('step-up' combination therapy); combination therapy with one or more synthetic DMARD and with glucocorticoids leads to better outcomes than DMARD monotherapy without glucocorticoids; and clinical and radiographic outcomes are better when a biologic agent is combined with methotrexate than with methotrexate monotherapy. These findings are very important and the authors are to be commended on the work they have performed and the results they present. Nevertheless, as with many systematic reviews, a number of questions arise.

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Authors and Affiliations

  1. JS Smolen is Professor of Medicine and Chairman of the Division of Rheumatology and D Aletaha is Associate Professor of Medicine, in the Division of Rheumatology at the Medical University of Vienna, Vienna, Austria.,

    Josef S Smolen & Daniel Aletaha

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  1. Josef S Smolen
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  2. Daniel Aletaha
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Correspondence to Josef S Smolen.

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Competing interests

JS Smolen has received honoraria and/or grant support from Abbott, Amgen, Bristol-Myers Squibb, Centocor-Schering-Plough, Roche, Sanofi-Aventis, UCB and Wyeth.

D Aletaha received honoraria and/or grant support from Abbott, Bristol-Myers Squibb, Centocor-Schering-Plough, Roche, Sanofi-Aventis and Wyeth.

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Smolen, J., Aletaha, D. Strengths and limitations of a systematic review on DMARDs for rheumatoid arthritis. Nat Rev Rheumatol 4, 296–297 (2008). https://doi.org/10.1038/ncprheum0813

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