somewordstoolate/Q2CRBench-3 huggingface dataset:
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Disease activity (follow up: range 4 months to 2 years; assessed with: ACR 70)
Importance: CRITICAL

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
rationales: Three studies at low risk of bias represent 60% of the weight.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: NOT_SERIOUS
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: HIGH
No of participants: Switch DMARDs: 266/1263 (21.1%)
Add DMARDs: 422/1658 (25.5%)
Effect: Relative Effect (95% CI): RR 0.84 (0.73 to 0.97)
Absolute Effect (95% CI): 41 fewer per 1,000 (from 69 fewer to 8 fewer)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Disease activity (follow up: range 4 months to 2 years; assessed with: DAS28 or DAS44 (lower values --> benefit) (values>0.2 are considered clinically important)
Importance: CRITICAL

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
rationales: Three studies at low risk of bias represent 60% of the weight.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due to serious imprecision. Confidence interval includes both values suggesting no effect and values suggesting harm. According to the Cochrane's handbook, Cohen suggested that SMD=0.2 be considered a 'small' effect size, 0.5 represents a 'medium' effect size and 0.8 a 'large' effect size. This means that if two groups' means do not differ by 0.2 standard deviations or more, the difference is trivial, even if it is statistically significant.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: MODERATE
No of participants: Switch DMARDs: 0
Add DMARDs: 0
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): SMD 0.24 SD higher (0.1 higher to 0.38 higher)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Remission (follow up: range 4 months to 1 year; assessed with: DAS remission < 2.6 )
Importance: CRITICAL

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due to serious imprecision. Confidence interval includes both values suggesting no effect and values suggesting benefit.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: MODERATE
No of participants: Switch DMARDs: 250/998 (25.1%)
Add DMARDs: 356/1367 (26.0%)
Effect: Relative Effect (95% CI): RR 0.85 (0.70 to 1.02)
Absolute Effect (95% CI): 39 fewer per 1,000 (from 78 fewer to 5 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Flare (follow up: 1 months)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias. Lack of allocation concealment and blinding.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due to serious imprecision. Confidence interval includes both values suggesting no effect and values suggesting harm.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch DMARDs: 0/155 (0.0%)
Add DMARDs: 1/152 (0.7%)
Effect: Relative Effect (95% CI): RR 0.33 (0.01 to 7.96)
Absolute Effect (95% CI): 4 fewer per 1,000 (from 7 fewer to 46 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Radiographic progression (follow up: 6 months; assessed with: mTSS (Lower values – > benefit) (MCID 4.6)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: NOT_SERIOUS
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: HIGH
No of participants: Switch DMARDs: 276
Add DMARDs: 277
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): MD 0.17 higher (0.14 higher to 0.2 higher)(The studies ACT-RAY and SURPRISE found that the RR of developing no radiographic progression (change in mTSS ≤0.5) was 0.96 (95%CI 0.91 to 1.02), absolute risk reduction 34 fewer per 1000 (95%CI 76 fewer to 17 more).)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Pain (follow up: range 4 months to 12 months; assessed with: VAS pain (0-100) (Lower values – > benefit) (MCID -11.9)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: NOT_SERIOUS
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: HIGH
No of participants: Switch DMARDs: 949
Add DMARDs: 1328
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): MD 1.9 higher (0.3 lower to 4.1 higher)(The study ORAL Strategy found that the RR of improvement in pain VAS (0-100) ≥ 10 was 0.99 (95% CI 0.92 to 1.07), absolute risk reduction 8 fewer per 1000 (95%CI 62 fewer to 54 more).)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Disability (follow up: range 4 months to 2 years; assessed with: HAQ-DI (Lower values – > benefit) (MCID -0.22)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias in three studies representing 55% of the weight.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: NOT_SERIOUS
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: MODERATE
No of participants: Switch DMARDs: 670
Add DMARDs: 673
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): MD 0 (0.06 lower to 0.07 higher)(The studies ADORE, ORAL strategy and Strand 2006, found that the RR of improvement in HAQ-DI (≥0.22 or ≥0.25 change from baseline) was 0.94 (95%CI 0.83 to 1.07), absolute risk reduction 39 fewer per 1000 (95%CI 112 fewer to 46 more).)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Fatigue (follow up: 1 year; assessed with: FACIT-F (Higher values – > benefit) (MCID 15.9)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: NOT_SERIOUS
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: HIGH
No of participants: Switch DMARDs: 384
Add DMARDs: 762
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): MD 0.62 lower (1.84 lower to 0.6 higher)(The study ORAL Strategy found that the RR of improvement in FACIT-F≥ 4 was 0.92 (95% CI 0.83 to 1.01), absolute risk reduction 55 fewer per 1000 (95%CI 117 fewer to 7 more).)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Quality of Life (follow up: 1 year; assessed with:  SF-36 MCS (Higher values – > benefit) (MCID 3.1)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: NOT_SERIOUS
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: HIGH
No of participants: Switch DMARDs: 384
Add DMARDs: 762
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): MD 0.97 lower (2.1 lower to 0.16 higher)(The study ORAL Strategy found that the RR of improvement in SF-36 MCS ≥ 2.5 was 0.94 (95% CI 0.84 to 1.05), absolute risk reduction 37 fewer per 1000 (95%CI 100 fewer to 31 more).)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Quality of Life (follow up: 1 year; assessed with: SF-36 PCS (Higher values – > benefit) (MCID 4.4)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: NOT_SERIOUS
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: HIGH
No of participants: Switch DMARDs: 384
Add DMARDs: 762
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): MD 0.87 lower (1.9 lower to 0.16 higher)(The studies ADORE, ORAL strategy and Strand 2006, found that the RR of improvement in HAQ-DI (≥0.22 or ≥0.25 change from baseline) was 0.94 (95%CI 0.83 to 1.07), absolute risk reduction 39 fewer per 1000 (95%CI 112 fewer to 46 more).)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Quality of Life (follow up: range 4 months to 2 years; assessed with: RAQol or EQ-5D VAS (lower values --> benefit) (values>0.2 are considered clinically important)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due to serious imprecision. Confidence interval includes both values suggesting no effect and values suggesting benefit. According to the Cochrane's handbook, Cohen suggested that SMD=0.2 be considered a 'small' effect size, 0.5 represents a 'medium' effect size and 0.8 a 'large' effect size. This means that if two groups' means do not differ by 0.2 standard deviations or more, the difference is trivial, even if it is statistically significant.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: MODERATE
No of participants: Switch DMARDs: 533
Add DMARDs: 529
Effect: Relative Effect (95% CI): -
Absolute Effect (95% CI): SMD 0.13 lower (0.25 lower to 0.01 lower)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Withdrawal due to lack of efficacy (follow up: range 4 months to 1 year)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due to serious imprecision. Confidence interval includes both values suggesting no effect and values suggesting harm. According to the Cochrane's handbook, Cohen suggested that SMD=0.2 be considered a 'small' effect size, 0.5 represents a 'medium' effect size and 0.8 a 'large' effect size. This means that if two groups' means do not differ by 0.2 standard deviations or more, the difference is trivial, even if it is statistically significant.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: MODERATE
No of participants: Switch DMARDs: 32/591 (5.4%)
Add DMARDs: 16/446 (3.6%)
Effect: Relative Effect (95% CI): RR 1.18 (0.59 to 2.36)
Absolute Effect (95% CI): 6 more per 1,000 (from 15 fewer to 49 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Withdrawal due to adverse events (follow up: range 3 months to 2 years)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: NOT_SERIOUS
rationales: Four studies at high risk of bias represent 40% of the weight. This is accounted for when downgrading for imprecision.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: VERY_SERIOUS
rationales: Downgraded by two levels due to serious imprecision. Confidence interval includes both values suggesting benefit and values suggesting harm.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch DMARDs: 101/1017 (9.9%)
Add DMARDs: 145/1392 (10.4%)
Effect: Relative Effect (95% CI): RR 0.91 (0.66 to 1.25)
Absolute Effect (95% CI): 9 fewer per 1,000 (from 35 fewer to 26 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Serious adverse events (follow up: range 3 months to 2 years)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias. Lack of allocation concealment and blinding.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due to serious imprecision. Confidence interval includes both values suggesting no effect and values suggesting harm. According to the Cochrane's handbook, Cohen suggested that SMD=0.2 be considered a 'small' effect size, 0.5 represents a 'medium' effect size and 0.8 a 'large' effect size. This means that if two groups' means do not differ by 0.2 standard deviations or more, the difference is trivial, even if it is statistically significant.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch DMARDs: 94/1009 (9.3%)
Add DMARDs: 113/1371 (8.2%)
Effect: Relative Effect (95% CI): RR 1.10 (0.85 to 1.42)
Absolute Effect (95% CI): 8 more per 1,000 (from 12 fewer to 35 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Malignancy (follow up: range 4 months to 2 years)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias. Lack of allocation concealment and blinding.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due serious imprecision. Low number of events.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch DMARDs: 3/598 (0.5%)
Add DMARDs: 6/978 (0.6%)
Effect: Relative Effect (95% CI): RR 0.65 (0.11 to 3.70)
Absolute Effect (95% CI): 2 fewer per 1,000 (from 5 fewer to 17 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on DMARD(s) who are NOT at target switch to another DMARD versus add a 2nd DMARD?
Population: Patients with RA on non-biologic DMARD(s) who are not at target
Intervention: Switch to another DMARD
Comparator: Add another DMARD
Outcome: Death (follow up: range 4 months to 2 years)
Importance: IMPORTANT

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias. Lack of allocation concealment and blinding.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: SERIOUS
rationales: Downgraded by one level due serious imprecision. Low number of events.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch DMARDs: 3/757 (0.4%)
Add DMARDs: 4/1133 (0.4%)
Effect: Relative Effect (95% CI): RR 0.92 (0.17 to 4.88)
Absolute Effect (95% CI): 0 fewer per 1,000 (from 3 fewer to 14 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on their first TNF Inhibitor who are NOT at target, switch to a 2nd TNF Inhibitor or switch to a boDMARD targeting a different molecule or to a tsDMARD?
Population: Patients with RA on their first TNF Inhibitor who are not at target
Intervention: Switch to a 2nd TNF Inhibitor
Comparator: Switch to Abatacept
Outcome: Disease activity (follow up: 1 year; assessed with: ACR 20)
Importance: CRITICAL

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias. Lack of blinding.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: VERY_SERIOUS
rationales: Downgraded by two levels due to very serious imprecision. Confidence interval includes both values suggesting benefit and values suggesting harm. Very small sample size, low number of events.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch to ABA: 11/31 (35.5%)
Switch to a 2nd TNFi: 17/31 (54.8%)
Effect: Relative Effect (95% CI): RR 0.65 (0.37 to 1.15)
Absolute Effect (95% CI): 192 fewer per 1,000 (from 345 fewer to 82 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on their first TNF Inhibitor who are NOT at target, switch to a 2nd TNF Inhibitor or switch to a boDMARD targeting a different molecule or to a tsDMARD?
Population: Patients with RA on their first TNF Inhibitor who are not at target
Intervention: Switch to a 2nd TNF Inhibitor
Comparator: Switch to Abatacept
Outcome: Disease activity (follow up: 1 year; assessed with: ACR 50)
Importance: CRITICAL

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias. Lack of blinding.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: VERY_SERIOUS
rationales: Downgraded by two levels due to very serious imprecision. Confidence interval includes both values suggesting benefit and values suggesting harm. Very small sample size, low number of events.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch to ABA: 6/32 (18.8%)
Switch to a 2nd TNFi: 9/31 (29.0%)
Effect: Relative Effect (95% CI): RR 0.65 (0.26 to 1.60)
Absolute Effect (95% CI): 102 fewer per 1,000 (from 215 fewer to 174 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio
Guideline: 2021 ACR RA
Clinical question: Should patients with RA on their first TNF Inhibitor who are NOT at target, switch to a 2nd TNF Inhibitor or switch to a boDMARD targeting a different molecule or to a tsDMARD?
Population: Patients with RA on their first TNF Inhibitor who are not at target
Intervention: Switch to a 2nd TNF Inhibitor
Comparator: Switch to Abatacept
Outcome: Disease activity (follow up: 1 year; assessed with: ACR 70)
Importance: CRITICAL

Evidence assessment:
GRADE: Risk of bias: result: SERIOUS
rationales: Downgraded by one level due to serious risk of bias. Lack of blinding.
Inconsistency: result: NOT_SERIOUS
Indirectness: result: NOT_SERIOUS
Imprecision: result: VERY_SERIOUS
rationales: Downgraded by two levels due to very serious imprecision. Confidence interval includes both values suggesting benefit and values suggesting harm. Very small sample size, low number of events.
Other considerations: result: none
Study design: Randomized Controlled Trial
Certainty: LOW
No of participants: Switch to ABA: 3/32 (9.4%)
Switch to a 2nd TNFi: 5/31 (16.1%)
Effect: Relative Effect (95% CI): RR 0.58 (0.15 to 2.23)
Absolute Effect (95% CI): 68 fewer per 1,000 (from 137 fewer to 198 more)
Abbreviations: CI: Confidence interval; RR: Risk ratio; MD: Mean difference; HR: Hazard Ratio