Early Rheumatoid Arthritis May Respond Well to Methotrexate Monotherapy



NEWPORT BEACH, CALIF. – Methotrexate alone is sufficient treatment for some cases of early rheumatoid arthritis, according to Dr. Daniel Furst.

Almost a third of patients "responded well to methotrexate alone" in several studies. For those who do, "long-term success can be anticipated with methotrexate alone," he said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

Because of that, "I try a patient on methotrexate first, and if she does really well, it’s good enough. If after 3 months or so she’s not doing really well, then adding other choices" – tumor necrosis factor inhibitors or other options – "makes a lot of sense," said Dr. Furst, the Carl M. Pearson professor of rheumatology at the University of California, Los Angeles.

In one of the studies proving the point, 493 patients with rheumatoid arthritis (RA) for less than a year and a mean disease activity score in 28 joints (DAS28) of 5.72 were treated with 20 mg/wk of methotrexate for 3-4 months. In 143 (29%) patients, DAS28 scores fell below 3.2, indicating low disease activity; 84 (17%) went into remission. Male gender, higher age, and lower baseline DAS28 all predicted response to methotrexate. Responders continued to improve throughout the 12 months of the study (Lancet 2009;374:459-66).

Etanercept may be a good add-on if patients need it. Although early RA patients seem to do as well clinically whether they receive methotrexate plus etanercept or triple therapy – methotrexate, sulfasalazine, and hydroxychloroquine – "on x-rays, triple therapy is not as good. The biologic, when added to methotrexate, slows x-ray progression more than triple therapy," Dr. Furst said (Arthritis Rheum. 2012;64:2824-35).

Methotrexate slows x-ray progression, too, but not as much as a biologic agent, he noted.

Corticosteroids may boost the effect of methotrexate in early RA, at least at first. In one study, 117 patients with symptoms for less than a year were randomized to methotrexate plus 10 mg/day of prednisone; 119 were randomized to methotrexate plus placebo (Ann. Intern. Med. 2012;156:329-39).

At first, methotrexate plus prednisone was better at reducing disease activity and physical disability, "but by about a year, there was [little] difference. What this says to me, and this is found in several studies, is that prednisone is pretty good stuff early on, but by 1 year you’ve lost most of your advantage," Dr. Furst said.

He reminded his audience that "you are immunosuppressing these patients, so before you start, you really ought to [check for] hepatitis B and C" as well as tuberculosis, and vaccinate patients as needed. Human papillomavirus and herpes zoster virus vaccinations "make sense when you are going to immunosuppress somebody," he said.

Dr. Furst disclosed relationships with Abbott, Amgen, Bristol-Myers Squibb, GlaxoSmithKline Novartis, Roche, and several other pharmaceutical companies. SDEF and this news organization are owned by Frontline Medical Communications.

   Comments ()

Recommended for You

News & Commentary

Quizzes from MD-IQ

Research Summaries from ClinicalEdge