Background/Purpose: While various studies have looked at possible RA therapies for undifferentiated arthritis (UA), there remains no consensus on optimal management strategies. We undertook a systematic review and meta-analysis to evaluate the efficacy of treatments used in patients with UA.

Methods: We searched in electronic databases (Medline, EMBASE, Web of Science, and The Cochrane Library) with no restrictions up to April 2014. We also searched the clinicaltrials.gov website and the list of references of relevant articles. Two reviewers independently screened citations and evaluated the risk of bias of the included studies.  Data was extracted by one reviewer and cross-checked by another. We performed direct comparison meta-analyses. 

Results:

Eight studies (nine publications) reporting on 931 participants were included. The majority (88%) had a low risk of performance and detection bias, but did not provide details to judge their risk of reporting bias. After reviewing the manuscripts, we decided to include five comparisons: (1) intra-articular triamcinolone combined with Sm-153 PHYP (a radiation synovectomy agent) versus triamcinolone alone, (2) methylprednisolone versus placebo, (3) methotrexate versus placebo/no intervention, (4) infliximab versus placebo, and (5) abatacept versus placebo. Patients on methylprednisolone were less likely to have started a DMARD compared to patients receiving placebo, at 6 months (RR 0.81, 95%CI 0.68-0.96).  Patients on methylprednisolone had less swollen (MD -1.0; -1.6, -0.40) and tender joints (MD -1.0; -2.0, -0.05), improved physician global assessment (MD -6.1; -11.7, -0.52) and quality of life (measured by the EQ5D; MD 0.08; 0.01, 0.15) compared to placebo, at 2 weeks to 12 months; however, compared to placebo there were more patients reporting adverse events in the methylprednisolone group (RR 1.8, 95% CI 1.0-3.3). Patients treated with methotrexate were less likely to develop RA (RR 0.31, 95% CI 0.18-0.53) or have radiographic progression (RR 1.3 95% CI 1.0-1.5) compared to patients treated without methotrexate, at 12-18 months. However, this difference was not observed at 30 months (RR 0.76, 95% CI 0.50-1.1) or 60 months (RR 0.86, 95% CI 0.59-1.3). Higher ACR20 response rates (RR 3.7; 1.3, 10.6), reduced swollen (MD -5.0; -9.8, -0.17) and tender joint counts (MD -13.0; -23.5, -2.5) and fatigue (MD 35.0; 15.6, 54.4) were observed in patients receiving infliximab compared to placebo at 3-6 months.  Similarly, patients receiving abatacept had better outcomes compared to patients receiving placebo including disease remission (RR 2.0; 1.1, 3.9), reduced swollen and tender joint count (RR 4.4; 1.5, 13.1), radiographic (MD -0.31; -0.40, -0.22) and MRI changes (MD -5.0; -7. 6, -2.4), at 6-12 months. No other statistically significant differences were found.

Conclusion: Treatment benefits were observed with all alternatives except for intra-articular use of a radiation agent plus triamcinolone versus triamcinolone alone.  Transient delay of RA development was only observed with methotrexate compared to control.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-treatment-of-undifferentiated-arthritis-a-systematic-review-and-meta-analysis-of-randomized-clinical-trials/