RA Treatment - Combination Therapy
Alan Matsumoto,
M.D.
Joan
Bathon, M.D.
Abstract 282 Methotrexate (M)-Hydroxychloroquine (H)-Sulfasalazine (S) vs M-H or M-S for Rheumatoid Arthritis: Results of A Double-Blind Study
J O'Dell, R Leff, G Paulsen, C Haire, J Mallek, PJ Eckhoff, A Fernandez, K Blakely, S Wees, S Hadley, J Felt, W Palmer, P Waytz, M Churchill, L Klassen, G Moore Omaha, NE
Previously, the investigators have published results demonstrating the superiority of the triple drug combination: methotrexate (M), hydroxychloroquine (H) and sulfasalazine (S) over methotrexate alone. The current study examines how the triple combination M-H-S compares with the double therapy of M-H and M-S. Presented are the results from 131 patients randomized to the three treatment groups followed for 2 years.
Groups ACR 20 ACR50
M-H-S 77% 46%
M-H 52% 36%
M-S 47% 23%
Editorial Comment: Not surprisingly, the triple combination was superior to either double combination and all the treatment groups were well tolerated. Of note is the magnitude of the benefit of triple therapy over the double therapy groups. The study demonstrates a strong argument for the triple combination.
Abstract 1852 Disease Modifying Antirheumatic Drugs (DMARD) and DMARD Combination Use by US Rheumatologists.
F Wolfe, DJ Hawley, T Pincus Wichita, KS, Nashville, TN
The perception among rheumatologists is that more aggressive treatment of rheumatoid arthritis (RA) will result in better outcomes. Two possible ways to assess aggressive treatment are: 1) number of patients on DMARDs, and 2) number of patients on combinations of DMARDs. Data from 6,073 patients with RA were available from the National Data Bank for Rheumatic Diseases established in 1998. Patients were asked to self-report on lifetime and current DMARD use, as well as current combination DMARD use. The average age of the patients was 59.7 years, average disease duration was 9.7 years, and 77% were women.
93% of patients reported ever having been on a DMARD in the following percentages: MTX 70%, hydroxychloroquine 53%, IM gold 34%, sulfasalazine 20%, auranofin 13.6%, azothioprine and D-penicillamine 10% each, leflunomide 6.1%, minocycline 6.0%; etanercept 4.7%, cyclosporine 3.9%; 68.4% of patients were also receiving prednisone.
76% reported currently receiving a DMARD: MTX 48%, hydrochloroquine 26%, IM gold 7.0%, leflunomide, azothioprine and etanercept 4.0% each, minocycline 2.8%, auranofin 2.7%, cyclosporine 1.6% ; 39.6 % were also receiving prednisone.
Current combination DMARD use was reported as follows: 0 DMARDs, 26%; 1 DMARD, 49%; 2 DMARDs, 18.9%; 3 DMARDs, 4.3%; 4 DMARDs, 1.1%. MTX + hydroxychloroquine was by far the most common 2 drug combination, and MTX + hydroxychloroquine + sulfasalazine the overwhelming choice for 3 drug combination therapy.
The authors conclude that combination DMARD therapy is still relatively uncommon in the U.S., and that MTX is the most commonly used DMARD.
Editorial comment: As Dr. Wolfe pointed out, these data reflect state of the art practice in the U.S. before the newer agents (leflunomide and TNF inhibitors) became widely available. It will be interesting to see how the use of DMARDs changes as more rheumatologists become familiar with the newer agents, particularly as new data showing their disease modifying properties evolves. It is perhaps discouraging to see that only 50% of RA patients are receiving even one DMARD.