First-line biologic and targeted synthetic DMARDs versus methotrexate in early rheumatoid arthritis: a meta-analysis of remission outcomes.
Mark D Russell, Chun J Chan, Aran Sasitharan et al.
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In 30 seconds
This systematic review and meta-analysis of randomized trials compared initial biologic and targeted synthetic DMARDs (b/tsDMARDs), alone or with methotrexate, against methotrexate in methotrexate-naïve adults with early rheumatoid arthritis. Across 29 trials involving 13 387 participants, combination therapy was associated with greater DAS28 remission at 6 months than methotrexate alone (risk ratio 1.62; 95% CI: 1.39, 1.89). Monotherapy also increased remission overall, although at the individual drug-class level, significantly higher rates were reported only for tocilizumab and JAK inhibitors.
Key findings
- Combination b/tsDMARD and methotrexate therapy increased DAS28 remission at 3 months (RR 1.95; 1.47, 2.57), 6 months (RR 1.62; 95% CI: 1.39, 1.89) and 12 months (RR 1.54; 1.39, 1.71) versus methotrexate alone.
- Combination therapy also improved CDAI remission and ACR50 response compared with methotrexate alone.
- As monotherapy, b/tsDMARDs increased DAS28 remission at 6 months (RR 1.81; 1.42, 2.31); significant class-level advantages were reported only for tocilizumab and JAK inhibitors.
- Combination-treatment benefits were greater in studies with higher baseline disease activity and a larger proportion of rheumatoid factor-positive participants.
Why it matters
The findings quantify remission advantages associated with starting b/tsDMARDs, particularly in combination with methotrexate, in early rheumatoid arthritis. They also indicate that monotherapy results may differ by drug class. These comparisons can inform interpretation of initial-treatment options, while the evidence remains based on trial-level pooled results rather than an individualized treatment recommendation.