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ID PMID Title PublicationDate abstract
19074912 Adaptation and cross-cultural validation of the rheumatoid arthritis work instability scal 2009 Nov BACKGROUND: Despite recent advances, work disability in rheumatoid arthritis (RA) remains common. Work disability is frequently preceded by a period of work instability characterised by a mismatch between an individual's functional abilities and job demands. This could raise the risk of work disability if not resolved. A work instability scale for RA (RA-WIS) has previously been developed to screen for this risk. The objective of this study was the adaptation of this scale into French, Dutch and German. METHOD: Different language versions of the RA-WIS were produced through a process of forward and back translations. The new scales were tested for face validity. English data from the original developmental study was pooled with data generated through postal surveys in each country. The internal construct and cross-cultural validity of the new scales were assessed using Rasch analysis, including differential item functioning (DIF) by culture. RESULTS: The pooled data showed good fit to the Rasch model and demonstrated strict unidimensionality. DIF was found to be present for six items, but these appeared both to cancel out at the test level and have only a marginal effect on the test score itself. CONCLUSIONS: The RA-WIS was shown to be robust to adaptation into different languages. Data fitted Rasch model expectations and strict tests of unidimensionality. This project and the continuing work on further cross-cultural adaptations have the potential to help ensure clinicians across Europe are able to support RA patients to achieve their potential in work through early identification of those most at risk.
20198931 Diagnosing joint pain in the older people. 2010 Jan There are many potential causes of joint pain in older patients. The most likely aetiology is OA. However, the differential diagnosis includes conditions which should not be missed such as septic arthritis and inflammatory disease. The pattern of joint involvement points to the diagnosis. Bilateral symmetrical small joint pain, swelling and stiffness should arouse the suspicion of RA. The wrist and knee are commonly affected by pseudogout and the first metatarsophalangeal joint or knee joint involvement may represent gout. Stiffness in the shoulder and hip girdles, worse in the morning, suggests polymyalgia rheumatica. In straightforward cases of OA no specific investigations are required. If doubt exists, however, tests may be necessary including FBC, ESR and CRP, uric acid for suspected gout and X-rays of the affected joints especially following trauma, or pseudogout. Patients with OA should be offered education and advice as well as strengthening exercises and aerobic fitness training (if physically possible). If the patient is overweight, weight loss is critical, especially in OA of the knee. Paracetamol and topical NSAIDs are the first-line drug treatments. Elderly onset RA differs from younger onset RA in the following ways: a more balanced gender distribution; a higher frequency of acute onset; an association with systemic features; more frequent involvement of the shoulder girdle and higher disease activity. DMARD therapy should be used according to disease severity, as in younger onset RA. The current approach is for early, intensive intervention with combination therapy. Corticosteroids may be very effective in the elderly, however, prolonged use and/or high dosage may lead to marked toxicity especially osteoporosis and diabetes.
19837205 Psychosocial factors, disease status, and quality of life in patients with rheumatoid arth 2009 Nov OBJECTIVE: To explore the interrelationships between the psychosocial and illness factors that determine the disease status of patients with rheumatoid arthritis (RA) and to identify how each factor is associated with quality of life (QOL). METHODS: The study group comprised 120 RA outpatients who completed a series of health examinations and questionnaires. Disease severity, functional disability, counts of swollen and/or tender joints, duration of RA, frequency of arthritis surgery, and C-reactive protein level were assessed by rheumatologists. Self-report inventories completed by the patients were used to assess perceived degree of pain, fatigue (visual analogue scales), depression (Beck Depression Inventory-II), anxiety (Hospital Anxiety and Depression Scale), and social support (Social Support Questionnaire). Mental and physical components of health-related QOL were evaluated using the Short-Form 36 Health Survey. RESULTS: After z-transformation of the data, a principal axis factor analysis was conducted. A four-factor structure was identified in which the components reflected psychosocial factors, disease activity, current symptoms, and physical functional status, respectively. There was no significant association between psychosocial factors and disease activity, while the other components were moderately correlated with each other. Multiple regression analysis revealed that physical QOL was determined by current symptoms and physical functions. Mental QOL was determined by psychosocial factors, current symptoms, and physical functions. CONCLUSION: Disease activity was independent from psychosocial factors and failed to reflect the perceived physical and mental QOL of RA patients. Clinicians should therefore evaluate psychosocial factors, as well as subjective disease status, to improve the QOL of patients with RA.
20551106 Scale characteristics and mapping accuracy of the US EQ-5D, UK EQ-5D, and SF-6D in patient 2010 Aug 1 OBJECTIVE: To compare the US EQ-5D with the UK EQ-5D and the SF-6D in patients with rheumatoid arthritis (RA). To provide mappings for each of the scales based on clinical variables. METHODS: We studied 12,424 patients with RA with 66,958 longitudinal observations using linear regression. In our mapping models we used the Health Assessment Questionnaire (HAQ) as a continuous predictor variable and as individual items. More complex models included the addition of a visual analog pain scale, the mood scale from the SF-36, and demographic and comorbidity covariates. We compared various models using root mean squared error (RMSE), in-sample and out-of-sample mean absolute error (MAE), and other measures of prediction accuracy and model fit. RESULTS: At any level of clinical severity, the US EQ-5D always had a higher utility score than the UK EQ-5D; and overall, the US scores were 0.094 units higher. The best models explained 64% to 72% of variance in utility scores, with RMSE values of 0.07 (SF-6D), 0.11 (EQ-5D US), and 0.17 (UK EQ-5D). There was a substantial increase in predictive accuracy by using pain and mood as predictor variables in the mapping. CONCLUSION: The US EQ-5D differs from the UK version and from the SF-6D in mean scores and ranges. When determined by mapping, the US EQ-5D has a much lower prediction error than the UK EQ-5D. Simple mapping models that use HAQ and pain have acceptable error rates, although more complex models that include mood scores and individual HAQ items substantially improve predictive accuracy.
20331862 A rational use of glucocorticoids in patients with early arthritis has a minimal impact on 2010 INTRODUCTION: Glucocorticoid (GC)-induced osteoporosis is a frequent complication in patients with rheumatoid arthritis. However, little information exists about the consequences of GC use in patients with early arthritis. Here we describe the variables underlying the use of GC in early arthritis, as well as its effect on bone-mineral density. METHODS: Data from 116 patients in our early arthritis register were analyzed (90 women; median age, 52.5 years, interquartile range (IQR, 38.5-66); 6-month median disease duration at entry (IQR, 4-9)). In this register, the clinical and treatment information was recorded systematically, including the cumulative GC dose. Lumbar spine, hip, and forearm bone-mineral density (BMD) measurements were performed at entry and after a 2-year follow-up. A multivariate analysis was performed to establish the variables associated with the use of GCs, as well as those associated with variations in BMD. RESULTS: Of the patients with early arthritis studied, 67% received GCs during the 2-year follow-up. GCs were more frequently prescribed to elderly patients, those with higher basal disease activity and disability, and patients with positive rheumatoid factor. When adjusted for these variables, GCs were less frequently prescribed to female patients. The use of GCs was associated with an increase of BMD in the ultradistal region of the forearm, although it induced a significant loss of BMD in the medial region of the forearm. No relevant effect of GC was noted on the BMD measured at other locations. CONCLUSIONS: The frequent use of GCs as a "bridge therapy" in patients with early arthritis does not seem to be associated with relevant loss of bone mass. Moreover, cumulative GC administration might be associated with an increase of juxtaarticular BMD.
20017888 Rituximab treatment in rheumatoid arthritis: how does it work? 2009 Treatment with the chimerical monoclonal antibody rituximab results in CD20-directed B cell depletion. Although this depletion is almost complete in the peripheral blood of nearly all patients with rheumatoid arthritis, a proportion of patients does not exhibit a clinical response. The paper by Nakou and colleagues suggests that a decrease in CD19+CD27+ memory B cells in both peripheral blood and bone marrow precedes the clinical response to rituximab. This finding adds to the emerging evidence that lack of response to rituximab is associated with persistence of B lineage cells in specific body compartments.
20430394 An update on the relationships between rheumatoid arthritis and atherosclerosis. 2010 Oct Rheumatoid arthritis is a chronic inflammatory disease. Cardiovascular events are the most important cause of mortality and morbidity in patients with rheumatoid arthritis. Beyond the traditional cardiovascular risk factors, chronic systemic inflammation has been shown to be a crucial factor in atherosclerosis development and progression from endothelial dysfunction to plaque rupture and thrombosis. Many studies have shown that atherosclerosis is not a passive event like accumulation of lipids in the vessel walls; by contrast, it represents an active inflammation of the vessels. Inflammatory cells such as macrophages, monocytes and T cells play important roles in the development of both rheumatoid arthritis and atherosclerosis. In this article we analyse the relationships between rheumatoid arthritis and atherosclerosis.
18927189 Common inflammatory mediators orchestrate pathophysiological processes in rheumatoid arthr 2009 Jan RA is characterized by a systemic inflammatory state, in which immune cells and soluble mediators play a crucial role. These inflammatory processes resemble those in other chronic inflammatory diseases, such as atherosclerosis. The chronic systemic inflammation in RA can be considered as an independent risk factor for the development of atherosclerosis, and represents an important field to investigate the reasons of the increase of acute cardiovascular events in RA. In the present review, we focused on several mediators of autoimmunity, inflammation and endothelial dysfunction, which can be considered the most promising targets to prevent atherogenesis in RA. Among several mediators, the pro-inflammatory cytokine TNF-alpha has been shown as a crucial factor to induce atherosclerosis in RA patients.
21149499 Smoking is a major preventable risk factor for rheumatoid arthritis: estimations of risks 2011 Mar BACKGROUND: Earlier studies have demonstrated that smoking and genetic risk factors interact in providing an increased risk of rheumatoid arthritis (RA). Less is known on how smoking contributes to RA in the context of genetic variability, and what proportion of RA may be caused by smoking. OBJECTIVES: To determine the association between the amount of smoking and risk of RA in the context of different HLA-DRB1 shared epitope (SE) alleles, and to estimate proportions of RA cases attributed to smoking. DESIGN: Setting and Participants Data from the Swedish Epidemiological Investigation of Rheumatoid Arthritis (EIRA) case-control study encompassing 1204 cases and 871 controls were analysed. Main Outcome Measure Estimated OR to develop RA and excess fraction of cases attributable to smoking according to the amount of smoking and genotype. RESULTS: Smoking was estimated to be responsible for 35% of anticitrullinated protein/peptide antibody (ACPA)-positive cases. For each HLA-DRB1 SE genotype, smoking was dose-dependently associated with an increased risk of ACPA-positive RA (p trend <0.001). In individuals carrying two copies of the HLA-DRB1 SE, 55% of ACPA-positive RA was attributable to smoking. CONCLUSIONS: Smoking is a preventable risk factor for RA. The increased risk due to smoking is dependent on the amount of smoking and genotype.
19211654 A dynamic exercise programme to improve patients' disability in rheumatoid arthritis: a pr 2009 Apr OBJECTIVE: To evaluate the functional, clinical, radiological and quality of life outcomes of a 4-week dynamic exercise programme (DEP) in RA. METHODS: Patients matched on the principal medico-social parameters were randomly assigned to either the DEP or the conventional joint rehabilitation group. Primary end point for judging effectiveness was functional status assessed by HAQ. Secondary outcomes included Nottingham Health Profile (NHP), Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF) and radiological worsening measured by Simple Narrowing Erosion Score (SENS). Clinical evaluation consisted of disease activity score (DAS 28), cycling aerobic fitness and dexterity. Dexterity was measured using Sequential Occupational Dexterity Assessment (SODA) and Duruoz Hand Index (DHI). Data were collected at baseline 1, 6 and 12 months. RESULTS: Fifty patients were enrolled. HAQ improved throughout the length of the trial in the DEP group. This improvement was greater in DEP than in the standard joint rehabilitation group at 1 month (-0.2 vs no variation from baseline, P = 0.04), but not at 6 months (-0.2 vs -0.1 in control group, P = 0.25) or 12 months (-0.1 vs no variation in control group, P = 0.51). DEP improved NHP (-23 vs + 7% in control group, P = 0.01) and aerobic fitness (+0.3 vs + 0.1 km per 5 min in control group, P = 0.02) at 1 month but the progress was not statistically significant thereafter. DEP also improved DHI, SODA, DAS 28 and AIMS2-SF, although not significantly. CONCLUSION: DEP was effective on functional status assessed by HAQ, quality of life and aerobic fitness at 1 month.
19410408 Quantification of synovitis in rheumatoid arthritis: do we really need quantitative measur 2009 Aug OBJECTIVE: The quantification of synovitis is of great significance for adequate therapy management and follow-up in patients with Rheumatoid Arthritis (RA). The purpose of this study was to validate a semi-quantitative Power Doppler (PD) scoring system by comparing the PD scores to the objective measurement of the synovial inflammation using dynamic contrast-enhanced Pulse-Inversion Harmonic Imaging (PIHI). MATERIALS AND METHODS: In 27 patients with RA, two radiologists performed semi-quantitative scoring of a PD examination, using a four-point scale from 0 to 3, in the metacarpophalangeal joints, proximal interphalangeal joints, and the wrists. The scores were compared to the area under the time-echo intensity curves obtained by contrast-enhanced PIHI examination. The interobserver agreement for PD scoring was evaluated using the Cohen's kappa test. RESULTS: Preliminary results showed that the area under the curve of dynamic measurements of PIHI tended to correlate with PD scores. The interobserver agreement for PD scoring was good (kappa=0.768). DISCUSSION: Based on comparisons with dynamic contrast-enhanced PIHI, semi-quantitative PD scoring might meet the criteria for a reliable, reproducible, and practical scoring system. Although further studies that would include a larger study population are required, our preliminary results show that PIHI may not provide a real benefit for quantification of synovitis in day-to-day practice.
19502267 The detecting and clinical value of anti-cyclic citrullinated peptide antibodies in patien 2009 Jul The aim of this article is to compare the prevalence of anti-cyclic citrullinated peptide (anti-CCP) antibodies in systemic lupus erythematosus (SLE) patients with and without arthritis and in patients with rheumatoid arthritis (RA). Anti-CCP antibodies were measured using ELISA in 159 SLE patients with arthritis (12 patients with erosive arthritis), 108 SLE patients without arthritis, 76 RA patients, and 87 healthy subjects (controls). The following had anti-CCP antibodies above the cut-off level (5 U/ml): 27.3% of SLE patients, 42.1% SLE patients with arthritis, 5.6% SLE patients without arthritis, 85.5% RA patients and 1.1% controls. The mean titre of anti-CCP antibodies in the SLE group was much lower than that in the RA group (33 +/- 72 vs. 160 +/- 125 U/ml), but higher in SLE patients with erosive arthritis than those with non-erosive arthritis (221 +/- 88 vs. 32 +/- 42 U/ml). Hand poly-arthritis occurred more frequently in anti-CCP-positive SLE patients with erosive arthritis than those with non-erosive arthritis. Anti-CCP antibodies were prevalent in some SLE patients, more prevalent in SLE patients with arthritis than those without arthritis. Anti-CCP-positive SLE patients were more likely associated with hand poly-arthritis, and high titre of anti-CCP antibodies might be used as a predictor for the complication of erosive arthritis.
20680284 Disability of Arm Shoulder and Hand Questionnaire in rheumatoid arthritis patients: relati 2011 Jun Rheumatoid arthritis (RA) is a systemic disease that causes disability. Disability and quality of life indexes are used in the assessment and treatment of patients with RA. Disability of Arm, Shoulder and Hand Questionnaire (DASH) is a patient-based outcome measurement developed to evaluate the upper extremities. The aim of this study was to investigate the clinical relevance of DASH in RA patients and the relationship between disease activity and health-related quality of life measurements. One hundred and sixty-six RA patients were included in the study. Disease activity was measured with Disease Activity Score 28 (DAS28), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI). The DASH questionnaire, Short-Form 36 (SF-36), and Health Assessment Questionnaire (HAQ) were completed by all patients. The DASH score moderately correlated with DAS28 (r=0.672), SDAI (r=0.586) and CDAI (r=0.565). When the patients were grouped according to the activity obtained using the three disease activity measurements, DASH score was statistically significantly higher with higher disease activity (P<0.001). A high correlation (r=0.883) was found between DASH and HAQ (r=0.883). The SF-36 scores were correlated with DASH (r=-0.785 with physical component, r=-0.619 with mental component). DASH scores correlate with disease activity indices, functional disability and QoL and can be used in the assessment of upper extremities in patients with RA.
20617358 Assessment of the validity of the 28-joint disease activity score using erythrocyte sedime 2010 Dec As tocilizumab (TCZ) greatly inhibits inflammatory markers, methods of evaluating rheumatoid arthritis (RA) disease activity that include inflammatory markers may overestimate the effect of TCZ treatment. We have evaluated the impact of inflammatory markers on the efficacy of TCZ by comparing the efficacy indicated by the 28-joint disease activity score using erythrocyte sedimentation rate (DAS28-ESR) with that indicated by the clinical and simplified disease activity indexes (CDAI and SDAI, respectively) and the American College of Rheumatology (ACR) core set criteria in a double-blind study of TCZ-the SATORI study. The Spearman correlation coefficient between DAS28-ESR and CDAI was comparable between that at week 24 and that at baseline [correlation coefficient at baseline and week 24 was 0.823 (p < 0.0001) and 0.818 (p < 0.0001), respectively]. A large difference between the DAS28 remission rate and CDAI remission rate was observed at week 24. However, these results are comparable to those of a previous study conducted with non-TCZ-treated patients. Moreover, the same results were obtained in the comparison between the DAS28-ESR and SDAI, even though the SDAI includes an inflammatory parameter as a component. These results confirm that the DAS28-ESR has a validity comparable to that of other methods in terms of evaluating the RA treatment efficacy of TCZ, despite its strong inflammatory marker-inhibiting effects.
20599872 Activities of enzymes that hydrolyze adenine nucleotides in platelets from patients with r 2010 Sep OBJECTIVES: To investigate whether there are changes in the activity of the enzymes NTPDase, 5'-nucleotidase, E-NPP and ADA in platelets from patients with rheumatoid arthritis (RA). DESIGN AND METHODS: Thirty-five RA patients diagnosed with RA through American College of Rheumatology criteria, as well as 35 healthy patients were selected. NTPDase, 5'-nucleotidase, E-NPP and ADA activities were verified in platelets isolated from these patients. RESULTS: The results demonstrate that an increase in NTPDase (approximately 100%), 5'-nucleotidase (170%), E-NPP (approximately 100%) and ADA (approximately 45%) activities occurred in RA patients when compared to the control group. CONCLUSIONS: Ours results suggest an increase in the NTPDase, 5'-nucleotidase and E-NPP activities, which could be related to a compensatory organic response to excessive platelet aggregation which occurs during the inflammation. The increased ADA activity found in this work could lead to a decrease in the adenosine concentration in the circulation, which could explain the accelerated atherosclerosis found in patients with RA.
18998141 Patients with active rheumatoid arthritis but only few tender and swollen joints: a subgro 2009 Apr The disease activity score of 28 joints (DAS28) is now commonly used for the guidance of treatment decisions in rheumatoid arthritis (RA). The goal of this work was to determine whether patients with DAS28 > 3.2 but less than 2 swollen and 2 tender joints respond differently to treatment than patients with a higher number of active joints. One hundred and ninety two patients with active RA treated in a rheumatology hospital as in-patients were studied prospectively. At admission (T1), release (T2) and 3 months after release (T3) disease activity (DAS28-CRP at T1 + 2, RADAI at T1 + 3), pain (numeric scale at T1 - 3) and function (FFbH at T1 + 3) were measured. A total of 148 patients had two or more (group 1) and 44 less than 2 swollen and tender joints at admission (group 2) but both groups had similar over all DAS28-scores. The groups significantly differed in their outcome after 3 months: group 1 had a significant better reduction of disease activity, pain and functional deficit (p < 0.001 for the fulfilment of defined response criteria and p < 0.05 for comparison of the mean values for pain and function) in comparison to group 2. Although the numbers were small sub-analysis suggested that the differences might be due to a better response to newly administered DMARD and TNF-alpha-inhibitor therapy in group 1. Active RA patients with less than 2 swollen and 2 tender joints represent a subgroup with lower response to treatment with DMARD or TNF-alpha-inhibitors. This has to be taken into account in the management of these patients.
20067593 Kitasato symposium 2009: new prospects for cytokine inhibition. 2009 The Kitasato Symposium 2009: New Prospects for Cytokine Inhibition was held in Berlin, Germany from 7 to 9 May 2009. The key aims of this meeting were to bring together a group of front-line researchers and rheumatologists to evaluate the use of cytokine blockade and to examine the role of certain cytokines in the pathogenesis of rheumatoid arthritis and other autoimmune diseases. A keynote lecture delivered by Professor Jean-Michel Dayer provided an up-to-date overview of the interactions occurring between the immune system and acute phase proteins. Other speakers discussed the role of cytokines in rheumatoid arthritis, including their role in joint destruction, as well as their regulatory role upon T cells and B cells. The involvement of cytokines in other autoimmune diseases was also addressed.
19651834 The effect of rheumatoid arthritis on the anatomy of the female cervical spine: a radiolog 2009 Aug The effect of rheumatoid arthritis on the anatomy of the cervical spine has not been clearly documented. We studied 129 female patients, 90 with rheumatoid arthritis and 39 with other pathologies (the control group). There were 21 patients in the control group with a diagnosis of cervical spondylotic myelopathy, and 18 with ossification of the posterior longitudinal ligament. All had plain lateral radiographs taken of the cervical spine as well as a reconstructed CT scan. The axial diameter of the width of the pedicle, the thickness of the lateral mass, the height of the isthmus and internal height were measured. The transverse diameter of the transverse foramen (d1) and that of the spinal canal (d2) were measured, and the ratio d1/d2 calculated. The width of the pedicles and the thickness of the lateral masses were significantly less in patients with rheumatoid arthritis than in those with other pathologies. The area of the transverse foramina in patients with rheumatoid arthritis was significantly greater than that in the other patients. The ratio of d1 to d2 was not significantly different. A high-riding vertebral artery was noted in 33.9% of the patients with rheumatoid arthritis and in 7.7% of those with other pathologies. This difference was statistically significant. In the rheumatoid group there was a significant correlation between isthmus height and vertical subluxation and between internal height and vertical subluxation.
18930987 Infliximab improves vascular stiffness in patients with rheumatoid arthritis. 2009 Aug OBJECTIVES: Patients with rheumatoid arthritis (RA) have increased cardiovascular mortality. Tumour necrosis factor alpha (TNFalpha)-blocking therapy has been shown to reduce RA disease activity measures and joint damage progression. Some observational studies suggest that TNFalpha blockade reduces mortality and incidence of first cardiovascular events. The mechanisms contributing to these outcomes are unclear. This study assessed the effects of infliximab treatment on vascular stiffness and structure in patients with RA. METHODS: A post hoc analysis of longitudinal data from a randomised placebo controlled study evaluated the effect of infliximab on vascular assessments. 26 patients received intravenous infliximab (3 mg/kg) at weeks 0, 2, 6 and every 8 weeks thereafter to week 54. Patients were followed up to 56 weeks of infliximab therapy with assessments of RA disease activity, cardiovascular risk factors, vascular stiffness (pulse wave velocity (PWV)), carotid intima media thickness (CIMT) and carotid artery plaque (CAP). Univariate analyses of changes over time by repeated measures analysis of variance (ANOVA) were followed by multivariate time-series regression analysis (TSRA) if changes were seen. RESULTS: PWV was significantly lower (better) after 56 weeks of treatment with infliximab (ANOVA p<0.01, TSRA p<0.01). However, CIMT (ANOVA p = 0.50) and CAP (chi(2) = 4.13, p = 0.88) did not change over the study period. Multiple cardiovascular risk measures did not change with treatment and did not correlate with changes in measures of vascular structure. CONCLUSIONS: Arterial stiffness improves with infliximab treatment in RA. This change may help explain the improved cardiovascular disease survival in patients with RA receiving TNFalpha-blocking therapy.
19821401 Abatacept for rheumatoid arthritis. 2009 Oct 7 BACKGROUND: Abatacept inhibits the co-stimulation of T cells and disrupts the inflammatory chain of events that leads to joint inflammation, pain, and damage in rheumatoid arthritis. OBJECTIVES: To assess the efficacy and safety of abatacept in reducing disease activity, pain, and improving function in people with rheumatoid arthritis. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (from 1966), EMBASE (from 1980), ACP Journal Club (from 2000), and Biosis Previews (from 1990) in March 2007 and December 2008. We contacted authors of included studies and the abatacept manufacturer. SELECTION CRITERIA: Randomized controlled trials comparing abatacept alone, or in combination with disease-modifying anti-rheumatic drugs (DMARDs) or biologics, to placebo or other DMARDs or biologics in patients with moderate to severe rheumatoid arthritis. DATA COLLECTION AND ANALYSIS: Two authors independently assessed search results and risk of bias, and extracted data. We obtained adverse event data from trials, long-term extension studies, and regulatory agencies. MAIN RESULTS: Seven trials with 2908 patients were included. Compared with placebo, patients in the abatacept group were 2.2 times more likely to achieve an ACR 50 response at one year (RR 2.21, 95% confidence interval (CI) 1.73 to 2.82) with a 21% (95% CI 16% to 27%) absolute risk difference between groups. The number needed to treat to achieve an ACR 50 response was 5 (95% CI 4 to 7). Significant improvements in physical function and a reduction in disease activity and pain were found in abatacept-treated patients compared to placebo. One RCT found abatacept significantly slowed the radiographic progression of joint damage at 12 months compared to placebo, although it is not clear what the clinical relevance of this difference may be. There may be a risk of attrition bias. Total adverse events were greater in the abatacept group (RR 1.05, 95% CI 1.01 to 1.08). Other harm outcomes were not significant with the exception of a greater number of serious infections at 12 months in the abatacept group (Peto odds ratio 1.91 (95% CI 1.07 to 3.42). Serious adverse events were increased when abatacept was given in combination with other biologics (RR 2.30, 95% CI 1.15 to 4.62). AUTHORS' CONCLUSIONS: There is moderate-level evidence that abatacept is efficacious and safe in the treatment of rheumatoid arthritis. Abatacept should not be used in combination with other biologics to treat rheumatoid arthritis. The withdrawal and toxicity profile appears acceptable at the present time but further long-term studies and post-marketing surveillance are required to assess harms and sustained efficacy.