POS0602 ROLE OF INTRAARTICULAR BIOLOGICS AND METHOTREXATE IN THE MANAGEMENT OF ACTIVE INFLAMMATORY MONOARTHRITIS
Authors: F. Aslam, M. Meyer, M. Pham
Journal: Annals of the Rheumatic Diseases (2021)

Background: Expansion of immunosuppressive medications has greatly improved disease activity control in rheumatoid arthritis (RA) patients. However, persistent symptomatic monoarthritis can be a problem in some patients who otherwise have satisfactory disease control. Intra-articular (IA) corticosteroid (CS) injections have remained a treatment cornerstone for these patients, but the need for other therapies is clear. Patients can fail such therapy, may develop adverse effects or have comorbidities that are exacerbated by IA CS. 50% of patients relapse after IA CS therapy. Several studies have looked at other agents such as methotrexate (MTX) or tumor necrosis factor inhibitors (TNF-i) as IA treatment options. Objectives: To systematically review the evidence regarding utility of IA methotrexate and biologics in managing inflammatory monoarthritis in patients with RA. Methods: A systematic literature review, in accordance with PRISMA guidelines, was conducted looking at trials investigating the use of IA MTX and/or TNF-i, against IA CS, in managing inflammatory monoarthritis in patients with RA. A trained librarian conducted search of Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science databases. Included studies were assessed for risk of bias as per the Cochrane tool. Results: A total of 1013 citations were retrieved from the medical database searches. 12 studies were included in the final review. 6 studies investigated IA MTX while 5 studied IA etanercept. One study investigated different biologic agents: infliximab, etanercept, or adalimumab. Multitude of dosing regimens and administration protocols were used in various studies. 5 of the 6 MTX studies only included knees. IA MTX was compared against saline, CS and as combined MTX/CS vs CS alone. There was no evidence to support the use of IA MTX as a superior or equivalent agent to the comparator groups. Unlike MTX, etanercept was investigated in multiple joint types e.g. elbows, knees and wrists. IA etanercept was found to have utility as a successful IA alternative to CS. The only study investigating infliximab and adalimumab found them to be superior to IA CS across multiple joint types. All therapies were generally well tolerated. Etanercept studies had low risk of bias while the MTX studies mostly suffered from higher risk of bias. Conclusion: Etanercept may be used as an IA agent in select patients with inflammatory arthritis when systemic treatment is not an option and IA corticosteroids cannot be used. Limited data also supports the utility of IA adalimumab and infliximab as better IA agents compared to CS. IA MTX, however, did not have such supporting data. References: [1]Fisher BA, Keat A. (2006) Should we be using intraarticular tumor necrosis factor blockade in inflammatory monoarthritis? J Rheumatol. 33(10), 1934-5. [2]Weitoft T, Uddenfeldt P. (2000) Importance of synovial fluid aspiration when injecting intra-articular corticosteroids. Ann Rheum Dis. 59(3), 233-5. Disclosure of Interests: None declared