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BMJ. 2007 December 1; 335(7630): 1119.
PMCID: PMC2099566
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So many drugs, so little evidence

Ann Intern Med on line 20 November 2007 ( Print date 15 January 2008

People with rheumatoid arthritis have plenty of treatment options. But doctors have little good evidence to help choose between them, according to a recent systematic review. After a close examination of nearly 30 years of research (101 studies), the only thing the authors could say with certainty was that no single disease modifying drug was clearly better than any other.

The two main groups of disease modifying drugs are the synthetic agents, such as methotrexate and sulfasalazine, and the anti-tumour necrosis factor agents, such as etanercept and infliximab. Used alone, methotrexate had similar clinical effects to the biological agents in this review. Both had similar side effect profiles, although the risks of long term rare or serious side effects are unknown. Combining treatments helped increase the chance of a response in patients who continued to deteriorate despite monotherapy. The evidence was too weak to support one combination over another. Bigger, better, and longer trials that include real world patients are urgently needed, say the authors. These trials should compare different treatment combinations and different treatment strategies directly, collect data on quality of life, and plan for subgroup analyses to help direct patients to the treatments most likely to work for them.

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