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Daily Medical Update
Adverse effects of antirheumatic drugs
Tuesday, August 18, 2026
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🔬 Practice-Changing Findings
Evidence from RCTs and meta-analyses published in the
last 12 months.
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European journal of clinical pharmacology (2026) - Systematic Review and Network Meta-Analysis
Key Findings
- b/tsDMARD monotherapy had a similar serious-infection incidence versus csDMARDs across 127 RCTs involving 55,749 patients.
- Adding csDMARDs to adalimumab, infliximab, tofacitinib, or upadacitinib increased serious-infection risk versus csDMARDs (odds ratios 1.51, 1.75, 2.52, and 2.31); certain targeted synthetic DMARDs also increased herpes-zoster incidence.
📋 Practice Implication: When escalating RA therapy, assess whether combination treatment adds infection risk and incorporate herpes-zoster prevention and monitoring into agent selection.
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The Cochrane database of systematic reviews (2026) - Systematic Review and Network Meta-Analysis
Key Findings
- After biologic or targeted synthetic DMARD failure, an untried TNF inhibitor had fewer adverse-event withdrawals than placebo (RR 0.32, 95% CrI 0.07–1.1).
- Sarilumab had more adverse-event withdrawals than placebo (RR 1.98, 95% CrI 0.57–7.19), while harm estimates for many alternatives remained imprecise and pairwise comparisons showed no significant differences.
📋 Practice Implication: After treatment failure, choose subsequent DMARDs according to the patient’s comorbidities and preferences because comparative harm evidence remains uncertain.
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Rheumatology (Oxford, England) (2026) - Meta-Analysis
Key Findings
- Across 64 placebo-controlled approval trials, total adverse-event and serious-adverse-event counts were comparable for biologic and targeted synthetic DMARDs versus placebo.
- More granular analyses showed distinct organ-class and adverse-event-of-special-interest patterns, with differences between compounds and classes despite comparable overall safety versus placebo.
📋 Practice Implication: A normal overall adverse-event rate should not replace drug-specific surveillance; monitoring should reflect the organ systems and special risks associated with the selected DMARD.
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Journal of autoimmunity (2026) - Systematic Review and Network Meta-Analysis
Key Findings
- In 27 studies involving 8,186 patients with RA-ILD, methotrexate, tocilizumab, and rituximab were associated with lower all-cause mortality.
- Abatacept plus methotrexate was associated with reduced ILD progression; antifibrotics preserved FVC or slowed decline, while JAK inhibitors had 7.9% discontinuation and 81.7% treatment retention.
📋 Practice Implication: For RA-ILD, regimen selection should integrate pulmonary outcomes and tolerability while treating these largely observational comparisons as hypothesis-generating.
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Clinical and experimental rheumatology (2026) - Systematic Review and Meta-Analysis
Key Findings
- Long-term low-dose glucocorticoid exposure was associated with increased cardiovascular events in pooled analysis (HR 1.37, 95% CI 1.03–1.81; p=0.01).
- The review found that prolonged use and higher cumulative doses were associated with a slight increase in cardiovascular risk versus shorter or lower exposure, particularly in patients with existing risk factors or comorbidities.
📋 Practice Implication: Use the cardiovascular signal to support steroid-minimization plans and periodic reassessment of cardiovascular risk in patients maintained on prednisone.
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Summary
Across five high-significance studies, antirheumatic-drug harms were most clearly tied to treatment combinations, herpes-zoster-prone agents, and prolonged glucocorticoid exposure rather than a uniform excess risk across all DMARDs. In rheumatoid arthritis, b/tsDMARD monotherapy had similar serious-infection risk to csDMARDs, while selected combinations increased serious infections; long-term low-dose glucocorticoids were associated with cardiovascular events (pooled HR 1.37). RA-ILD findings suggested outcome differences among regimens but were largely observational, so treatment selection should be individualized with attention to infection, pulmonary, and cardiovascular risk.
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