Triple DMARD Therapy More Effective than Methotrexate Monotherapy in Patients with Rheumatoid Arthritis

Functional ability in early rheumatoid arthritis (RA) can be improved with intensive initial therapy with triple disease modifying anti-rheumatic disease (DMARD) drugs, according to results of a study presented at the European League Against Rheumatism Annual Congress (EULAR 2015) Press Conference in Rome, Italy in June.

Researchers from the Maasstad Hospital in the Netherlands randomized groups of RA patients in order to test out the theory of monotherapy vs. combination therapy regimen of methotrexate, sulfasalazine, and hydroxychloriquine with bridging glucocorticoid together. The patients received the treatment for 2 years.

After the observation period, the researchers measured the patients’ disease activity score (DAS) 44, a composite score of disease activity. The percentage of patients who attained a DAS 44 score was less than 1.6 at 2 consecutive time points of sustained remission. That was similar among patients who initiated triple DMARD therapy (51 percent) and monotherapy (47 percent).

Functional ability was also measured among the patients and was evaluated using the Health Assessment Questionnaire (HAQ). In a period of 3 months, HAQ scores were significantly greater in the triple DMARD therapy group and the scores remained constant throughout the 2 year observation period, no matter the disease activity score. Using x rays, the researchers saw similar joint damage progression for both medication regimen groups.

“Many trials have shown that early and intensive treatment can induce remission and prevent joint damage in patients with RA, yet often a step wise approach of escalating treatment is preferred,” lead author Angelique Weel, MD, PhD, Department of Rheumatology at the Maasstad Hospital in the Netherlands, explained in a press release. “Our data showed an earlier decrease in disease severity and improvements in functional ability in the combination therapy groups compared to monotherapy, adding to the evidence base for an intensive treatment approach early on. And with significant numbers of patients achieving drug free remission using less expensive biologicals during the first 2 years of therapy, these data should alleviate concerns regarding the need for long term aggressive therapy.”

The exacerbations of symptoms after tapering each medication group was similar among combination triple therapy and monotherapy groups, the researchers determined. The researchers believe that an initial treatment regimen of methotrexate, sulfasalazine, and hydroxychloriquine could provide significant patient benefits over a monotherapy of methotrexate alone.

The study was part of the tREACH study, in which researchers evaluated which treatments are best for patients, including those in combination. The results of this study are aligned with other studies conducted by the investigation group, including one from 2013 that again found triple therapy was better than methotrexate alone. And in 2014, a similar conclusion was reached.