Rheumatologists in the United States are calling for changes to prescribing practices so that clinicians use methotrexate more effectively.

In a large analysis of prescribing patterns in the US Dr James O’Dell from the Nebraska Medical Center and colleagues found that the well-accepted anchor drug for treating rheumatoid arthritis methotrexate was currently under-used and sub-optimally dosed in clinical practice.

Writing in Arthritis Care & Research the researchers noted that the TEAR trial showed that patients with early onset poor prognosis RA given a six month trial of MTX before adding a conventional DMARD or biologic did just as well clinically and radiographically at two years when compared to those that received either combination therapy.

However their analysis that included approximately 274 million patients revealed that in 2009 a quarter of patients received a biologic before ever being treated with MTX.

And of those who did receive MTX first, only 37% were on MTX doses of greater than 15 mg/week at the time of adding or switching to a biologic.

“This clearly demonstrates that even when MTX was used the majority of patients are treated with suboptimal MTX doses,” the researchers wrote.

They also noted that clinicians moved to biologics rapidly with 41% stopping oral MTX therapy after three months.

“MTX is accepted as the anchor DMARD in RA; however this study highlights that this anchor drug is dramatically underutilized in clinical practice with suboptimal dosing, inadequate duration of monotherapy, and failure to administer it in its most bioavailable way – subcutaneously,” the study authors concluded.

“Efforts should be made to change MTX prescription practices to improve utilization of our anchor RA treatment, MTX,” they added.