by Dr. Simi Paknikar on  July 3, 2013 at 2:37 PM Health In Focus
Combination DMARDs Effective in Methotrexate-Resistant Rheumatoid Arthritis Cases
According to recent research, treatment with a combination of DMARDs is an effective alternative to using a biological agent in the treatment of rheumatoid arthritis.

With newer treatments available, rheumatoid arthritis patients now lead a more comfortable and pain-free life. Doctors usually start the treatment with a drug called methotrexate, which belongs to the group Disease Modifying Anti-Rheumatic Drugs (DMARDs).  If the patient does not respond to the medication, a biological agent is usually added.  The other option is to add additional DMARDs to methotrexate.

The newer biological therapies have transformed the lives of many. These include therapies which belong to a group referred to as the tumor necrosis factor (TNF) inhibitors.  However, biological treatment has a huge price tag attached to it, and may not be economically feasible to a number of patients.

A study published in the New England Journal of Medicine compared patient response to a combination of conventional DMARDs and methotrexate, and the use of the biological agent etanercept with methotrexate in patients who were already taking methotrexate and yet suffered from active disease.

One group of patients received three drugs, sulfasalazine and hydroxychloroquine and methotrexate; this group is referred to as the triple therapy group.  The second group received weekly etanercept injections with methotrexate. Patients who did not respond to one therapy were shifted to the other after 24 weeks of treatment.  In addition, the participants could also take their nonsteroidal anti-inflammatory drugs (NSAIDs) and prednisone when needed.

Statistical analyses of the results available from 309 patients who completed the study indicate that treatment with the triple therapy is not inferior to the etanercept-methotrexate therapy.  There were no significant radiological changes between the two groups at the end of 48 weeks. Both the groups had a similar number of patients that switched treatment by 24 weeks.  People who switched the treatment to the alternative treatment showed improvement at the end of 48 weeks. 

Though patients on etanercept-methotrexate therapy showed better results at 24 weeks of treatment, the results were similar at the end of 48 weeks. This may indicate a faster response to the etanercept-methotrexate therapy in some cases.

The frequency of adverse events due to the treatments was similar in both groups. While digestive tract disorders were more frequent in patients on the triple therapy, infections and disorders of the skin and subcutaneous tissue were more common with the etanercept-methotrexate therapy.  The number of serious adverse events was more common in the etanercept-methotrexate group.

Thus, the researchers suggest that rheumatoid arthritis patients who do not respond to methotrexate should be first switched to a combination of DMARDs like the triple therapy used in this study.  Those who do not respond to this treatment can move over to a combination like etanercept-methotrexate.  This approach could reduce the cost of treatment for quite a few patients without compromising on the clinical outcome of the disease.

Reference :

Therapies for Active Rheumatoid Arthritis after Methotrexate Failure; James Dell et al; NEJM 2013

Source: Medindia

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