WebMD Medical News
Louise Chang, MD
Oct. 21, 2009 (Philadelphia) -- For many people with rheumatoid arthritis,
the traditional, and much cheaper, disease-modifying antirheumatic drugs
(DMARDs) appear to work just as well as newer TNF blockers that target the
underlying disease process, a large study shows.
The findings also suggest that a step-up approach in which patients are
started on methotrexate alone, with additional drugs added only if needed, may
be preferable to immediate combination treatment, says Larry W. Moreland, MD,
chief of rheumatology at University of Pittsburgh.
Moreland and colleagues studied 755 patients, mostly white women. All had
early rheumatoid arthritis, with an average of less than four months since
diagnosis, and had not yet received disease-modifying antirheumatic drugs
The study was designed to compare the older and the newer drugs and to look
at the benefit of starting with combination therapy compared to step-up
The patients were divided into four groups. Two groups began with immediate
combination therapy: either methotrexate combined with sulfasalazine and
hydroxychloroquine (the traditional DMARDs) or methotrexate and the TNF blocker
The other two groups began with methotrexate alone, with step-up treatment
adding either sulfasalazine/hydroxychloroquine or Enbrel only if they had
persistent disease activity at six months.
Two years later, there was no significant difference in disease activity
between patients taking triple DMARD therapy or methotrexate + Enbrel. This
held true whether they received immediate combination treatment or step-up
“What this means in real clinical practice is that patients should be
started on methotrexate alone, with other drugs added only if they don’t
respond,” Moreland says.
“You always want to try to expose the patient to as few drugs as possible,”
Although the traditional DMARDs worked just as well in the study as the TNF
blocker, Moreland isn’t ready to conclude that holds true for all patients.
"While the results may show that, overall, both treatments have similar
outcomes, we still are not certain how to best treat individual patients," he
Moreland tells WebMD that X-ray images, taken during the study, may show
whether one strategy is better at halting disease progression. But those images
aren't available yet.
“We clearly need better predictors of who will benefit from which
treatment,” says Mayo Clinic rheumatologist John Davis, MD. He moderated a news
conference to discuss the new studies at the annual meeting of the American
College of Rheumatology.
In the meantime, Davis tells WebMD he tries to prescribe the least
aggressive treatment that works. “I have patients that do very well on
methotrexate alone,” he says.
SOURCES:American College of Rheumatology Annual Meeting, Philadelphia, Oct. 17-21,
2009.Larry W. Moreland, MD, chief of rheumatology, University of Pittsburgh.John Davis, MD, assistant professor of medicine, division of rheumatology,
Mayo Clinic, Rochester, Minn.
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