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.
OBJECTIVE: To perform a systematic review (SR) on the effectiveness of self-management interventions, in order to inform the European League Against Rheumatism Recommendations for its implementation in patients with inflammatory arthritis (IA). METHODS: The SR was conducted according to the Cochrane Handbook and included adults (≥18 years) with IA. The search strategy was run in Medline through PubMed, Embase, Cochrane Library, CINAHL Plus with Full Text, and PEDro. The assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. A narrative Summary of Findings was provided according to the Grading of Recommendations, Assessment, Development and Evaluation. RESULTS: From a total 1577 references, 57 were selected for a full-text review, and 32 studies fulfilled the inclusion criteria (19 randomised controlled trials (RCTs) and 13 SRs). The most studied self-management components were specific interactive disease education in ten RCTs, problem solving in nine RCTs, cognitive-behavioural therapy in eight RCTs, goal setting in six RCTs, patient education in five RCTs and response training in two RCTs. The most studied interventions were multicomponent or single exercise/physical activity in six SRs, psychosocial interventions in five SRs and education in two SRs. Overall, all these specific components and interventions of self-management have beneficial effects on IAs-related outcomes. CONCLUSIONS: The findings confirm the beneficial effect of the self-management interventions in IA and the importance of their implementation. Further research should focus on the understanding that self-management is a complex intervention to allow the isolation of the effectiveness of its different components.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
BACKGROUND: Psychological interventions are an important but often overlooked adjunctive treatment option for patients with rheumatoid arthritis. Findings from systematic reviews of psychological interventions for this patient group are conflicting. A systematic review of reviews can explain inconsistencies between studies and provide a clearer understanding of the effects of interventions.
OBJECTIVES: To: 1) determine the effectiveness of psychological interventions in improving biopsychosocial outcomes for adults with rheumatoid arthritis, 2) determine the relationship between the intensity of the psychological interventions (number of sessions, duration of sessions, duration of intervention) on outcomes, and 3) assess the impact of comparator group (usual care, education only) on outcomes.
DESIGN: We conducted a systematic review of reviews using the following inclusion criteria: 1) randomised controlled trials of psychological interventions (including cognitive behavioural therapy, supportive counselling, psychotherapy, self-regulatory techniques, mindfulness-based cognitive therapy and disclosure therapy) provided as an adjunct to medication, 2) included rheumatoid arthritis patients aged ≥ 18 years, 3) reported findings for at least 1 of the primary outcomes: pain, fatigue, psychological status, functional disability and disease activity and 4) were published in English between January 2000 and March 2015 (updated January 2018).
DATA SOURCES: We searched in MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. Reference lists were searched for additional reviews.
REVIEW METHODS: Study selection and 50% of the quality assessments were performed by two independent reviewers. Methodological quality was measured using the Assessment of Multiple Systematic Reviews checklist. Data extraction was conducted by one reviewer using a predesigned data extraction form.
RESULTS: Eight systematic reviews met inclusion criteria (one review was excluded due to its low-quality score). Small post intervention improvements in patient global assessment, functional disability, pain, fatigue, anxiety and depression were observed. The effect on coping, self-efficacy and physical activity was greater. Improvements in depression, coping and physical activity were maintained (8.5-14 months). Interventions delivered over a longer period with a maintenance component appeared more effective. Attention, education, and placebo control groups produced some improvements but not as large as those produced by the psychological interventions.
CONCLUSIONS: Psychological interventions result in small to moderate improvements in biopsychosocial outcomes for patients with rheumatoid arthritis in addition to those achieved by standard care. Several priorities for future research were identified, including determining the cost effectiveness of non-psychologically trained health professionals delivering psychological interventions.
Esta revisión evalúa críticamente la literatura sobre la medicina complementaria y alternativa (CAM) como opciones de tratamiento para la artritis reumatoide y la osteoartritis. Diseño: Se realizaron búsquedas en bases de datos electrónicas para identificar todas las revisiones pertinentes sistemáticas de la efectividad de la CAM en la artritis reumatoide y la artrosis publicados entre enero de 2010 y enero de 2011. Las críticas fueron definidas como sistemática si incluyeran inclusión explícita y repetible y criterios de exclusión para los estudios. La calidad metodológica se evaluó mediante los criterios de Oxman para las revisiones sistemáticas. Resultados: Cinco revisiones sistemáticas cumplieron los criterios de inclusión. Todos llegaron a conclusiones prudentes. Cuatro opiniones eran de alta calidad y una fue cargado con alto riesgo de sesgo. La evidencia que apoya la eficacia de la CAM como una opción de tratamiento para la artritis reumatoide y la osteoartritis es ambiguo.
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.
