The results come from a meta-analysis of 70 randomized trials, either placebo or drug controlled, that included 112 comparisons.
The researchers point out that the immunoselective biologic drugs introduced in the past 10 years are expensive, so it is important to make full use of older, cheaper drugs. The purpose of their meta-analysis was to determine the difference in effect on joint destruction between DMARDs (used alone or in combination therapy), glucocorticoids and biologic therapy.
As a standardized measure of joint destruction progression, they divided radiographic score changes with the observation time between two scorings, to derive the percentage of the annual radiographic progression rate (PARPR).
Dr. Niels Graudal at Copenhagen University Hospital, and Dr. Gesche Jürgens at Bispebjerg University Hospital report their results in Arthritis & Rheumatism, published online June 17.
“Single DMARD treatment and glucocorticoids significantly reduce radiographic joint destruction with a relative effect of 50-65% compared with placebo,” they write. “Aggressive combination therapy with 2-3 DMARDs, DMARD/glucocorticoid or DMARD/biologic reduces radiographic joint destruction with a relative effect of 50-80% compared with single DMARD therapy.”
Specifically, compared to placebo, the PARPR was 0.90% smaller with a single DMARD (p<0.00001) and 0.54% smaller with a glucocorticoid (p<0.00001). Compared with a single DMARD, the PARPR was 0.80% smaller with combination DMARDs (p<0.001) and 0.63% smaller with a biologic plus methotrexate (p<0.00001).
Furthermore, combining two DMARDs with step-down glucocorticoids was as effective as a biologic plus methotrexate (PARPR -0.07%; p=0.44).
“Consequently, biologics should still be reserved for DMARD-resistant patients,” the two investigators conclude.
They add that in future trials, biologics for rheumatoid arthritis should be compared with combination DMARD-glucocorticoid treatment.
Arthritis Rheum 2010.