Dr. Singh is a Professor in the Division of Rheumatology and Clinical Immunology. The primary goal of Dr. Singh’s research is to improve the outcomes of patients with arthritis and rheumatic conditions. The objectives of Dr. Singh’s research program are, (1) to advance evidence-based medicine by performing state-of-the-art Cochrane Systematic Reviews, Meta-analyses and Network Meta-analyses as well as the development and dissemination of treatment guidelines that can change the way we provide the best care to patients with rheumatic conditions, and (2) to improve our understanding of what impacts poor patient outcomes, including pain and function in arthritis, and design interventions to improve these outcomes.

Abstract
Biologics are a major advance in the treatment of rheumatoid arthritis (RA), the most common autoimmune inflammatory arthritis in adults. Serious infections are a major concern for patients considering treatments for RA. Evidence is inconsistent as to whether biologics are associated with an increased risk of serious infection compared with traditional disease-modifying antirheumatic drugs (DMARDs). We performed a systematic review and network meta-analysis of serious infections in patients treated with biologics compared with those treated with traditional DMARDs. The systematic review identified 106 trials. Compared with traditional DMARDs, standard-dose biologics (OR 1.31, 95% credible interval [CrI] 1.09-1.58) and high-dose biologics (1.90, 1.50-2.39) were associated with an increased risk of serious infections, although low-dose biologics (0.93, 0.65-1.33) were not. The risk was lower in patients who were methotrexate-naive compared with traditional DMARD-experienced or anti-tumor necrosis factor biologic-experienced patients. The absolute increase in the number of serious infections per 1000 patients treated each year ranged from six for standard-dose biologics with/without traditional DMARD, 17 for high-dose biologics with/without traditional DMARD, to 55 for combination biologic therapy, compared with traditional DMARDs. Our study shows that clinicians should discuss the balance between benefit and harm with the individual patient before starting treatment with biologics for rheumatoid arthritis.