Methotrexate has Dominant role in Treatment of Rheumatoid Arthritis: JAMA

In a groundbreaking analysis, researchers have conducted the first network meta-analysis examining the outcomes associated with various conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and glucocorticoids in patients suffering from rheumatoid arthritis. This comprehensive study sheds light on the effectiveness of methotrexate as the primary reference conventional synthetic disease-modifying antirheumatic drug in the treatment of rheumatoid arthritis. 

The study results were published in the journal JAMA Network Open. 

Since the discovery of rheumatoid arthritis (RA) numerous synthetic disease-modifying antirheumatic drugs (csDMARDs) have been developed. Previous RA assessments focused on joint inflammation and systemic factors. This study aims to analyze multiple csDMARDs and Glucocorticoids in RA treatment, emphasizing frequently reported outcomes like tender joint count, swollen joint count, erythrocyte sedimentation rate, and C-reactive protein level, adjusting for potential effect modifiers in integrated RCTs. 

For the study researchers meticulously reviewed English language articles without time constraints, sourced from prestigious databases like MEDLINE, Embase, Cochrane Central, ClinicalTrials.gov, and pertinent meta-analyses' reference lists until September 15, 2022. The research team, comprising four reviewers working in pairs, independently selected controlled studies. These studies involved randomizing rheumatoid arthritis patients into various groups, including mono-csDMARDs, glucocorticoids, placebos, or nonactive treatments.

The criteria for inclusion were studies recording at least one outcome related to parameters such as tender joint count, swollen joint count, erythrocyte sedimentation rate, and C-reactive protein level. Among the 1098 articles assessed, 130 articles, encompassing 132 interventions, met the stringent inclusion criteria. The primary outcome, tender joint count, was meticulously evaluated, utilizing imputations based on other outcomes to ensure a comprehensive analysis of all studies. 

Key findings: 

• The study revealed intriguing insights based on 29 interventions across 275 treatment groups in 132 randomized clinical trials.
• These interventions involved a significant cohort of 13,260 rheumatoid arthritis patients. 
• Oral methotrexate, in comparison to a placebo, led to a substantial reduction in tender joint count by 5.18 joints.
• Moreover, when compared to methotrexate, glucocorticoids, and other drugs, excluding cyclophosphamide, demonstrated similar or even lower tender joint counts, signifying the efficacy of these treatments. 

Thus, the study reinforces methotrexate's position as the primary reference conventional synthetic disease-modifying antirheumatic drug in the treatment of rheumatoid arthritis. The findings not only provide valuable guidance for healthcare professionals but also offer hope to millions of patients battling this debilitating condition.

Further reading: Guski LS, Jürgens G, Pedder H, et al. Monotreatment With Conventional Antirheumatic Drugs or Glucocorticoids in Rheumatoid Arthritis: A Network Meta-Analysis. JAMA Netw Open. 2023;6(10):e2335950. doi:10.1001/jamanetworkopen.2023.35950