Pharmacological and Non-pharmacological Therapeutic Strategies in Difficult-to-treat Rheumatoid Arthritis: a Systematic Literature Review Informing the EULAR Recommendations for the Management of Difficult-to-treat Rheumatoid Arthritis

Overview

Journal RMD Open

Publisher BMJ Publishing Group

Specialty Rheumatology

Date 2021 Jan 9

PMID 33419871

Citations 27

Authors

Nadia M T Roodenrijs

Attila Hamar

Melinda Kedves

Gyorgy Nagy

Jacob M van Laar

Desiree van der Heijde

Paco M J Welsing

Affiliations

Soon will be listed here.

Abstract

Objectives: To summarise, by a systematic literature review (SLR), the evidence regarding pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis (D2T RA), informing the EULAR recommendations for the management of D2T RA.

Methods: PubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised.

Results: Two hundred seven (207) papers studied therapeutic strategies. Limited evidence was found on effective and safe disease-modifying antirheumatic drugs (DMARDs) in patients with comorbidities and other contraindications that limit DMARD options (patients with obesity, hepatitis B and C, risk of venous thromboembolisms, pregnancy and lactation). In patients who previously failed biological (b-)DMARDs, all currently used b/targeted synthetic (ts-)DMARDs were found to be more effective than placebo. In patients who previously failed a tumour necrosis factor inhibitor (TNFi), there was a tendency of non-TNFi bDMARDs to be more effective than TNFis. Generally, effectiveness decreased in patients who previously failed a higher number of bDMARDs. Additionally, exercise, psychological, educational and self-management interventions were found to improve non-inflammatory complaints (mainly functional disability, pain, fatigue), education to improve goal setting, and self-management programmes, educational and psychological interventions to improve self-management.The identified evidence had several limitations: (1) no studies were found in patients with D2T RA specifically, (2) heterogeneous outcome criteria were used and (3) most studies had a moderate or high risk of bias.

Conclusions: This SLR underscores the scarcity of high-quality evidence on the pharmacological and non-pharmacological treatment of patients with D2T RA. Effectiveness of b/tsDMARDs decreased in RA patients who had failed a higher number of bDMARDs and a subsequent b/tsDMARD of a previously not targeted mechanism of action was somewhat more effective. Additionally, a beneficial effect of non-pharmacological interventions was found for improvement of non-inflammatory complaints, goal setting and self-management.

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