Abstract
BackgroundPersistent monoarthritis in otherwise well-controlled rheumatoid arthritis presents a therapeutic challenge. Intra-articular (IA) steroids are a mainstay of treatment, though some have queried whether IA disease modifying anti-rheumatic drugs (DMARD) and biologics can be used in those who fail steroid injections.MethodsA systematic literature review was conducted using four medical databases to identify randomized, controlled trials assessing IA therapies in RA patients. Included studies underwent Cochrane Risk of Bias 2 assessment for quality.ResultsTwelve studies were included, 6 of which examined intra-articular (IA) TNF inhibitors (TNFi), and 6 studies evaluating IA methotrexate. Of those evaluating IA TNFi, one study reported statistical improvement in TNFi therapy when compared with placebo. The remaining 5 studies compared IA TNFi therapy with steroid injections. IA TNFi had statistically improved symptom scores and clinical assessments comparable with IA steroid treatments.In the 6 studies evaluating IA methotrexate, the addition of methotrexate to steroid intra-articular therapy was not found to be beneficial, and singular methotrexate injection was not superior to the control arms (saline or triamcinolone). Risk-of-bias (ROB) assessment with the Revised Cochrane ROB tool indicated that 2 of 6 TNFi studies were at some risk or high risk for bias, compared with 5 out of 6 methotrexate studies.ConclusionFor persistent monoarthritis in rheumatoid arthritis, IA methotrexate was not found to have clinical utility. Intra-articular TNFi therapy appears to have equal efficacy to IA steroids, though the optimal dose and frequency of injections is yet unknown.
Highlights
Persistent monoarthritis in otherwise well-controlled rheumatoid arthritis presents a therapeutic challenge
Sullivan et al BMC Musculoskeletal Disorders (2021) 22:792 situation arises in some patients with isolated inflammatory monoarthritis, without an associated systemic disease or even an underlying diagnosis, where systematic immunosuppressive treatment may seem aggressive compared to the more localized IA therapy
Search strategy and information sources A literature search was conducted on 10th August 2020 by a trained, experienced medical librarian utilizing medical subject heading (MeSH) and text words related to the study question
Summary
Persistent monoarthritis in otherwise well-controlled rheumatoid arthritis presents a therapeutic challenge. The continued expansion of immunosuppressive medication options has greatly improved disease activity control in rheumatoid arthritis (RA) patients. Sullivan et al BMC Musculoskeletal Disorders (2021) 22:792 situation arises in some patients with isolated inflammatory monoarthritis, without an associated systemic disease or even an underlying diagnosis, where systematic immunosuppressive treatment may seem aggressive compared to the more localized IA therapy. After exhausting IA steroid treatments, therapeutic paths forward are unclear. In such situations, surgical and radiation-induced synovectomy have been employed as treatment approaches [3, 4]. Several studies have looked at the utility of other IA immunosuppressive treatments as a management option for persistent inflammatory monoarthritis. The aim of this systematic review was to evaluate the suitability and effectiveness of IA methotrexate and/or IA TNF-i to treat persistent monoarthritis in RA patients
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