Limitations to evidence based medicine

A limitation of the EBM approach is that as questions get more specific the evidence becomes less available. EBM can be quite good at answering broad brush answers questions, but these are rarely what clinicians actually need. Here is a recent example, taken from a recent NICE guideline on rheumatoid arthritis (pdf)

The available data does not answer the clinical question of whether a patient who is not responding to DMARD therapy should go onto other conventional DMARDs or onto a biological drug. There are no head to head trials of these comparators.

This question, about switching to another low cost DMARD or to a high cost biologic, important as it is, doesn't seem to have an answer. The problem in part is that the underlying research agenda regarding the effectiveness of therapeutics is motivated (of course) by commercial concerns, as we showed 15 years ago in an analysis of NSAIDS for osteoarthritis.

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