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 (DMARDs).
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 therapy.
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 Enbrel.
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.
Arthritis Drugs: No Difference between DMARDs, TNF Blockers
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 therapy.
“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,” he says.
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 says.
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.