He noted that the 2012 ACR recommendations indicate that a patient’s DMARD should be switched if he or she has low disease activity after three to six months of DMARD monotherapy or if the patient has at least moderate disease activity after three months of MTX. The guidelines indicate that a biologic should be added in cases of low disease activity and poor prognosis or moderate disease activity after three to six months of MTX monotherapy or DMARD combination therapy. Switching between biologics should be done with at least moderate disease activity after three to six months after failing an anti-TNF biologic, the guidelines state.
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But Dr. Emery referenced several studies showing that a first-line biologic may offer higher remission rates and that if a target is not reached at six months, biologics are better than DMARDs. These include studies showing that treatment with adalimumab plus MTX is more effective than treating with MTX alone and that treatment of early RA with etanercept and MTX leads to clinical outcomes not seen with MTX alone.4-6
Although making sense of all the data out there isn’t easy, the main points are that early diagnosis is key and remission correlates with long-term benefits, Dr. Emery said. “We only have the luxury of maintenance therapy if we actually induce something with a more aggressive approach,” he said.
Stephanie Cajigal is a medical journalist based in California.
- Aletaha D, Neogi T, Silman A, et al. 2010 Rheumatoid arthritis classification criteria: An ACR/EULAR collaborative initiative. Arthritis Rheum. 2010;62:2569-2581.
- Freeston JE, Wakefield RJ, Conaghan PG, Hensor EM, Stewart SP, Emery P. A diagnostic algorithm for persistence of very early inflammatory arthritis: The utility of power Doppler ultrasound when added to conventional assessment tools. Ann Rheum Dis. 2010;69:417-419.
- Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64:625-639.
- Kavanaugh A, Fleischmann RM, Emery P, et al. Clinical, functional and radiographic consequences of achieving stable low disease activity and remission with adalimumab plus methotrexate or methotrexate alone in early rheumatoid arthritis: 26-week results from the randomised, controlled OPTIMA study. Ann Rheum Dis. 2013;72:64-71.
- Detert J, Bastian H, Listing J, et al. Induction therapy with adalimumab plus methotrexate for 24 weeks followed by methotrexate monotherapy up to week 48 versus methotrexate therapy alone for DMARD-naive patients with early rheumatoid arthritis: HIT HARD, an investigator-initiated study. Ann Rheum Dis. 2013;72:844-850.
- Emery P, Kvien TK, Combe B, et al. Combination etanercept and methotrexate provides better disease control in very early (<=4 months) versus early rheumatoid arthritis (>4 months and <2 years): Post hoc analyses from the COMET study. Ann Rheum Dis. 2012;71:989-992.