Treatment strategies in patients with rheumatoid arthritis for whom methotrexate alone has failed: data from the NOR-DMARD register

Taken from NRAS magazine, Winter 2011

Rheumatologists from several centres  in Norway and the Netherland, using data from the NOR-DMARD register,  looked at the effectiveness of adding a TNF inhibitor to methotrexate in those patients for whom methotrexate alone had not been effective and compared the outcomes with a second group of patients whose response to methotrexate had also  been inadequate but who were given another standard disease modifying anti rheumatic drug  eg sulfasalazine, hydroxychloroquine, before the addition of a TNF inhibitor.

At the start of the study both groups of patents had similar baseline activity.  Three- and six month effectiveness and 2-year drug survival were better for  those in the methotrexate and TNF inhibitor group (MTX+TNFi) than for those in the group taking  methotrexate in combination with another standard DMARDs (MTX+sDMARDs). Effectiveness was somewhat better with triple therapy 9 (3 standard DMARDS given together) than other MTX+sDMARD combinations but was generally inferior compared with MTX+TNFi. For the patients who received MTX+TNFi as a third step after MTX+sDMARDs had failed (n=38) there was a tendency towards lower remission rates, worse disease activity states and inferior drug survival compared with patients who received MTX+TNFi directly after the failure of MTX.

The study group concluded that effectiveness was better for MTX+TNFi than for MTX+sDMARDs. Patients who started MTX+TNFi after two standard DMARD regimens had failed had a tendency not to do so well after 3 months as patients who switched directly from MTX to MTX+TNFi.

Ann Rheum Dis2011;70:2103-2110 doi:10.1136/ard.2011.152363