OBJECTIVES : Rheumatoid arthritis (RA) is the most common autoimmune disease in the world. Rheumatologists prescribe conventional synthetic disease-modifying antirheumatic drugs (csDMARD) or biological agents (BA) for disease remission. Currently BAs are prescribed broadly, even in first line therapy despite the great impact on additional cost. Our study aimed to compare the effectiveness in RA remission of treatment with combination of csDMARD and BA.

METHODS : A systematic search of Medline, Embase, Cochrane databases and grey literature was conducted. Eligible studies included randomized clinical trials and remission data was evaluated according to DAS-28. Identified citations were screened independently in duplicate for eligibility and the studies methodological quality was evaluated with Risk of Bias tool. Data were extracted independently for studies characteristics and remission was considered for DAS-28 score < 2.6. Results were pooled using inverse variance fixed effect meta-analysis.

RESULTS : The search retrieved 610 studies, 6 randomized trials were included. The combination of csDMARD were mainly methotrexate, sulfasalazine and hydroxychloroquine and the most cited biologic were etanercept, adalimumab and infliximab. After 6 months, the absolute risk reduction was 0.032 (95%CI 0.001 to 0.068), NNT=31 and RR = 0.70 (95%CI 0.57 to 0.85) in favor of biological agent therapy. At 12 to 24 months, there was no statistically significant difference between both therapies, with an absolute risk difference of 0.036 (95%CI -0.017 to 0.090), NNT=28 and RR = 0.91 (95%CI 0.80 to 1.05). Serious adverse events were similar, RR = 0.90 (95%CI 0.64 to 1.28). Heterogeneity tests confirmed some clinical differences between studies.

CONCLUSIONS : There is no difference on RA remission status between the csDMARD and BA after one year therapy, suggesting a cost minimization study. The remission occurred early with BA comparing with csDMARDs.