Evidence for treating rheumatoid arthritis to target: results of a systematic literature search

Monika Schoels, Rachel Knevel, Daniel Aletaha, Johannes W J Bijlsma, Ferdinand C Breedveld, Dimitrios T Boumpas, Gerd Burmester, Bernard Combe, Maurizio Cutolo, Maxime Dougados, Paul Emery, Desirée van der Heijde, Tom W J Huizinga, Joachim Kalden, Edward C Keystone, Tore K Kvien, Emilio Martin-Mola, Carlomaurizio Montecucco, Maarten de Wit, Josef S Smolen, Monika Schoels, Rachel Knevel, Daniel Aletaha, Johannes W J Bijlsma, Ferdinand C Breedveld, Dimitrios T Boumpas, Gerd Burmester, Bernard Combe, Maurizio Cutolo, Maxime Dougados, Paul Emery, Desirée van der Heijde, Tom W J Huizinga, Joachim Kalden, Edward C Keystone, Tore K Kvien, Emilio Martin-Mola, Carlomaurizio Montecucco, Maarten de Wit, Josef S Smolen

Abstract

Objectives: To summarise existing evidence on a target oriented approach for rheumatoid arthritis (RA) treatment.

Methods: We conducted a systematic literature search including all clinical trials testing clinical, functional, or structural values of a targeted treatment approach. Our search covered Medline, Embase and Cochrane databases until December 2008 and also conference abstracts (2007, 2008).

Results: The primary search yielded 5881 citations; after the selection process, 76 papers underwent detailed review. Of these, only seven strategic clinical trials were extracted: four studies randomised patients to routine or targeted treatment, two compared two different randomised targets and one compared targeted treatment to a historical control group. Five trials dealt with early RA patients. All identified studies showed significantly better clinical outcomes of targeted approaches than routine approaches. Disability was reported in two studies with no difference between groups. Four studies compared radiographic outcomes, two showing significant benefit of the targeted approach.

Conclusion: Only few studies employed randomised controlled settings to test the value of treatment to a specific target. However, they provided unanimous evidence for benefits of targeted approaches. Nevertheless, more data on radiographic and functional outcomes and on patients with established RA are needed.

Conflict of interest statement

Competing interests This study was supported by an unrestricted educational grant from Abbott Immunology. Abbott had no influence on the selection of papers, extraction of data or writing of this manuscript. Francis Berenbaum was the Handling Editor.

Figures

Figure 1
Figure 1
Flow chart of the systematic literature search. Illustrated are the results of the initial search and the selection process of abstract screening, full text review and hand search. AB, abstract; ACR, American College of Rheumatology; EULAR, European League Against Rheumatism; RA, rheumatoid arthritis.
Figure 2
Figure 2
Design of the seven core clinical trials. (A) TICORA study (Grigor et al 2004); (B) CAMERA study (Verstappen et al 2007); (C) Fransen et al 2005; (D) Symmons et al 2005; (E) Edmonds et al 2007 (abstract); (F) van Tuyl et al 2008; and (G) Stenger et al 1998. Intensive and routine treatment arms are displayed, red arrows mark the scheduled intervals for target assessment. Table 1 specifies the targets of trials A–G. AZA, Azathioprine; CAMERA, Computer Assisted Management in Early Rheumatoid Arthritis; CRP, C reactive protein; DAS, Disease Activity Score; DMARD, disease-modifying antirheumatic drug; HCQ, hydroxychloroquine; IFX, ifosfamide; LDA, low disease activity; LEF, leflunomide; MTX, methotrexate; NSAID, non-steroidal anti-inflammatory drug; sc, subcutaneous; SJC, swollen joint count; sod., sodium; SPZ, sulfinpyrazone; TICORA, tight control of rheumatoid arthritis.

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Source: PubMed

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