Triple DMARD Induction Regimen Beats MTX Monotherapy in Early RA

Starting patients with early RA on triple combination therapy with disease modifying anti-rheumatic drugs (DMARDs), rather than escalating therapy with a step-wise approach, significantly improves disease activity and functional ability over 2 years, Dutch researchers report.

Results of the treatment in the Rotterdam Early Arthritis CoHort (tREACH) trial, presented at the 2015 European League Against Rheumatism (EULAR) Congress in Rome, Italy, also suggest that an initial regimen of methotrexate (MTX), sulfasalazine, and hydroxychloroquine, plus a “bridging” glucocorticoid, provides substantial – and earlier -- benefits than MTX monotherapy (with glucocorticoid).

Moreover, the study shows that patients starting out on combination DMARD therapy “reach their targets earlier… and could taper their medications earlier than those on monotherapy,” says lead author Angelique Weel, MD, of the Department of Rheumatology, Maasstad Hospital in the Netherlands.

Such early and intensive treatment is not widely used in RA due to worries about side effects, Dr. Weel commented at a EULAR news conference. “But we have already showed within our study, and in other studies, that the side effects are not higher in the combination therapy compared to monotherapy with methotrexate.” The incidence of RA flares was also similar.

In the tREACH trial, 281 patients with early RA (68% of whom were women) were randomized to the triple DMARD therapy or to MTX monotherapy.

The endpoint was a disease activity in 44 joints (DAS44) score of less than 1.6 at 2 two consecutive time points – a composite score considered to be sustained remission.  Actual medication use was obtained from medical charts and from patient diaries.

DMARDs, either synthetic and/or biologic, were tapered in a stepwise fashion after a median of 9 months if DAS44 was below 1.6 at 2 consecutive time points, according to the study abstract.

After just 3 months, the triple therapy group achieved greater improvements in functional ability, seen in Health Assessment Questionnaire (HAQ) scores, than the MTX group. Results remained significant throughout the 2 years, irrespective of disease activity.

Similar percentages in both groups (51% vs 47%) achieved sustained remission and were able to taper their medications at 6 or 24 months, displaying minimal progression of joint damage on X-rays; 11% of patients had drug-free remission at 2 years.

In the current era of treat-to-target, “the most valuable outcome measure is functional ability,” Dr. Weel concludes.

References:

Kuijper T, Luime J,de Jong P, et al. Tapering DMARDS in the TREACH trial - flare rates, sustained remission and radiological progression. EULAR 2015; Rome: Abstract OP0030