Intended for healthcare professionals

Clinical Review State of the Art Review

How to use biologic agents in patients with rheumatoid arthritis who have comorbid disease

BMJ 2015; 351 doi: (Published 17 August 2015) Cite this as: BMJ 2015;351:h3658

Chinese translation


  1. John S Richards, staff rheumatologist12,
  2. Sharon M Dowell, assistant professor of medicine3,
  3. Mercedes E Quinones, assistant professor of medicine3,
  4. Gail S Kerr, chief of rheumatology123
  1. 1Veterans Affairs Medical Center, Washington DC 20422, USA
  2. 2Georgetown University, Washington, DC, USA
  3. 3Howard University, Washington, DC, USA
  1. Correspondence to J S Richards john.richards1{at}


Although biologic disease modifying anti-rheumatic drugs (bDMARDs) have improved the quality of life of patients with rheumatoid arthritis, side effects remain a problem, especially for patients with pre-existing comorbidities. Randomized controlled trials of such drugs in rheumatoid arthritis typically exclude patients with comorbidities and are of short duration, so they do not provide data on adverse events in these people. Other data sources such as national bDMARD registries are limited by the preselection of patients for both conventional synthetic chemical compound disease modifying anti-rheumatic drugs (csDMARDs) and bDMARDs, and although these databases document comorbidity, they rarely report its severity. This too limits definitive statements on the progression or resolution of pre-existing disease. Although bDMARDs may not be contraindicated in patients with rheumatoid arthritis and certain comorbid diseases, additional assessments or precautions are recommended. This review summarizes current data on the use of bDMARDs in people with rheumatoid arthritis and common comorbid diseases. It provides an evidence base for doctors and their patients when discussing and selecting the appropriate bDMARDs.


  • Thanks to Jan Edmiston for her assistance with database searches and to the patients at the Washington DC Veterans Affairs Medical Center for their review of the manuscript and comments.

  • Contributors: All authors helped in the design of the work; the acquisition, analysis, and interpretation of the data; and the revision of the manuscript. All authors approved the version to be published and are accountable for all aspects of the article. JSR is guarantor.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • The views expressed in this article are those of the authors and do not necessarily reflect the positions or policies of the Department of Veterans Affairs or the Federal Government of the United States.

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