Rheumatoid arthritis

How to treat RA patients when methotrexate has failed?

Patients who fail initial treatment with methotrexate have a greater reduction in disease activity if switched to a biological rather than conventional synthetic DMARD, results from a ‘real world’ study suggest.

In a one year follow up of 512 patients with newly diagnosed RA, Dutch researchers found that those who switched to a bDMARD had a significantly lower Disease Activity Score (DAS) at six and 12 months compared to patients who switched to a csDMARD or a csDMARD combined with glucocorticoid.

Patients who switched to a bDMARD also had lower risk of subsequent treatment switching than those taking a csDMARD, suggesting they had a more sustained response, according to the study by Dutch researchers published in Annals of Rheumatic Diseases.

Using data from the METEOR registry of observational study data, the researchers used multiple propensity scores to adjust for bias such as disease severity (confounding by indication).

In their study, the 89 patients who switched to a bDMARD after methotrexate failed showed a change in DAS of -2.0 at six months and -0.91 at 12 months. In comparison the changes in DAS were -0.96 and -0.43 at 6 and 12 months for patients who switched to csDMARDs and glucocorticoid, and -0.73 and -0.39 for patients who received csDMARDs only.

Patients receiving a bDMARD had a lower risk for discontinuing treatment (Hazard Ratio 0.38) than patients receiving a csDMARD, but there were no differences between patients who did or did not receive glucocorticoid.

Stable treatment was an average of two months longer in the bDMARD group compared to the csDMARD-only group and one month longer than the csDMARD and glucocorticoid group.

The researchers said their results were in line with some randomised controlled trials that showed superiority of bDMARD treatment over csDMARD therapies after methotrexate failure.

“ …from a societal perspective and depending on the exact medication costs, escalating to a bDMARD, resulting in a rapid clinical improvement, may be cost efficient, but further research into this topic is needed,” they wrote.

“Furthermore, treatment-survival was better in patients receiving treatment with a bDMARD. This could have important consequences for clinical practice, when choosing among treatment strategies in patients who fail initial methotrexate treatment,” they concluded.

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