How do tumor necrosis factor (TNF) inhibitors compare to methotrexate (MTX) in the treatment of rheumatoid arthritis (RA)?

Updated: Feb 07, 2020
  • Author: Howard R Smith, MD; Chief Editor: Herbert S Diamond, MD  more...
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In one study, bone erosions showed a higher rate of repair in RA patients treated with TNF inhibitors than in patients treated with MTX. [79] After a 1-year follow-up, the group treated with TNF blockers showed a mean width of 2 mm and a mean depth of 2.3 mm; the MTX-treated group showed a mean width of 2.4 mm and a mean depth of 2.4 mm. Deeper lesions in the TNF-inhibitor group were also particularly prone to repair when compared with more shallow lesions. [79]

Van Vollenhoven et al reported that in patients with early RA who have MTX-treatment failure, the addition of a TNF antagonist was superior to the addition of conventional DMARDs. [80] In this study, 258 patients with early RA who did not achieve low disease activity after 3-4 months of MTX (up to 20 mg/wk) were randomized to receive additional treatment (in addition to MTX) either with SSZ and HCQ or with infliximab.

In the SSZ and HCQ group, 32 of 130 (25%) achieved the primary outcome, defined as a good response according to the European League Against Rheumatism (EULAR); in the infliximab group, 50 of 128 (39%) attained the primary outcome. [80]

A systematic review by Visser et al suggested that an initial oral MTX dose of 15 mg/wk, with escalation of 5 mg/mo to achieve target doses of 25-30 mg/wk or maximum tolerable doses, was the optimal evidence-based dosing strategy. [81] Starting at higher initial doses or escalating too rapidly may be limited by toxicity. Conversion from oral to subcutaneous (SC) administration of MTX is suggested for patients who have an inadequate response to oral therapy.

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