RA Strategy: Treat Early, but With What Medicines?

By Kathleen Doheny
WebMD Health News

Reviewed by Arefa Cassoobhoy, MD, MPH

Oct. 30, 2013 (San Diego) -- Most experts agree it's best to treat rheumatoid arthritis early -- and some say aggressively -- as soon as the diagnosis is made.

But debate continues about what medications are best to use first, and in what combinations. Some experts think patients should use three medications, known as triple DMARDs (disease-modifying antirheumatic drugs), from the start. Others favor starting with a single medication.

The old mantra ''start low, go slow" is out the door, says Kam Nola, PharmD. She is an associate professor of pharmacy at Lipscomb University's College of Pharmacy in Nashville.

About 1.3 million Americans have RA, a chronic and potentially disabling disease that causes pain, stiffness, and swelling, and limits how joints work. The American College of Rheumatology recommends starting with methotrexate (Rheumatrex, Trexall) alone for most patients, then switching or adding other drugs if necessary. These include other DMARDs, as well as the more expensive injected biologics.

At a news conference Tuesday at the annual meeting of the American College of Rheumatology, several researchers shared study findings that looked at specific treatment strategies.

Here is what they found:

Single Drug Vs. Triple DMARD

Using three traditional DMARD medications works better than a single drug, says Pascal de Jong, PhD. He is a researcher at Erasmus Medical Center in the Netherlands. He looked at 281 patients who had had symptoms less than 6 months.The patients received one of four treatments:

  • Triple therapy included methotrexate, sulfasalazine and hydroxychloroquine, with corticosteroids either by pills or a muscle injection.
  • Single therapy was methotrexate alone with either corticosteroid treatment.

''We saw that if you started the combination of DMARDs, you achieved low disease activity after 3 months," de Jong says. "It's very important to have disease control very early." The results lasted for a year.

Another plus of the triple regimen, he says: "If you start with the combination of DMARDS, you can more often taper the medications [as symptoms improve]."

The DMARD triple treatment was also more cost-effective, de Jong says. Those on it stayed more productive at work, he also found.

Triple DMARDs Vs. Anti-TNFs

The triple DMARD treatment gives results similar to biologic drugs known as anti-TNFs (anti-tumor necrosis factor agents). This was true whether patients used the drugs in combination with methotrexate from the beginning, or if they added them 6 months later as a next step.

A benefit of the triple therapy: It's less expensive, says researcher Kaleb Michaud, PhD, an assistant professor at the University of Nebraska Medical Center. Michaud looked at how cost-effective the treatments were. He also at looked at the patients' quality of life. While all strategies worked equally well, the triple strategies were most cost-effective over the long term. The biologics cost nearly twice as much, Michaud says. In the future, this information could help doctors and their patients choose treatment options when cost is an issue.

Choosing RA Drugs

In the U.S., rheumatologists typically choose single therapy first if the disease is in early stages, says Eric Ruderman, MD. He is a professor of medicine at Northwestern University Feinberg School of Medicine. He reviewed the new research. If that's not working, many rheumatologists will then add a biologic (usually injected), then if necessary a triple DMARD regimen with a biologic, he says.

"Initial triple DMARD therapy is a very hard sell," Ruderman says. The regimen includes about 50 pills a week, he says.

Many patients balk at that number, he says. They prefer to start with a single medication and see if that controls the disease.

Ruderman reports doing consulting work for several pharmaceutical companies.

The new research ''suggests we need to be treating RA more aggressively early," Nola says. Figuring out the exact medication or medications, she says, must be tailored to the patient.

These findings were presented at a medical conference. They should be considered preliminary, as they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.

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SOURCES: Kaleb Michaud, PhD, assistant professor, University of Nebraska Medical Center, Omaha.Pascal de Jong, PhD, researcher, Erasmus Medical Center, Netherlands.Kam Nola, PharmD, associate professor of pharmacy practice, Lipscomb University College of Pharmacy, Nashville.Eric Ruderman, MD, professor of medicine, Northwestern University Feinberg School of Medicine, Chicago. Has worked for AbbVie, Amgen, BMS, Celgene, Janssen, Lilly, Medac, Pfizer, and Vertex.Annual meeting, American College of Rheumatology, San Diego, Oct. 26-30, 2013.

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