Jonathan Kay, MD


July 12, 2013

Practice-Changing Results?

This primary outcome was measured at 48 weeks. During the first 24 weeks of the study, both groups had significant improvement compared with baseline, and this improvement was comparable in each group. A switch in treatment was made for 27% of the participants in each group as a result of inadequate response to the initial therapy. Participants in both groups who switched therapies improved after switching to the other therapy, and the response after switching did not differ significantly between the 2 groups.

A similar change in DAS28 occurred between baseline and 48 weeks in the 2 groups -- a reduction of 2.1 with triple therapy and of 2.3 with etanercept in combination with methotrexate. This difference was not statistically significant. Triple therapy was found to be noninferior to etanercept and methotrexate because the 95% upper confidence limit of 0.41 for the difference in change in DAS28 was below that prespecified margin for noninferiority of 0.6. There was no significant between-group difference in secondary outcomes, including radiographic progression, pain, and health-related quality of life, or in adverse events associated with medications. This study concluded that triple therapy of hydroxychloroquine, sulfasalazine, and methotrexate was noninferior to etanercept and methotrexate in patients inadequately responsive to methotrexate treatment for rheumatoid arthritis.

Will this change practice? Most rheumatologists prescribe tumor necrosis factor (TNF) inhibitors for patients inadequately responsive to methotrexate. However, triple therapy is less expensive and, according to this study, just as effective. Perhaps the results of this study will prompt rheumatologists to try adding hydroxychloroquine and sulfasalazine instead of a TNF inhibitor, perhaps reducing the cost of care for patients with rheumatoid arthritis previously inadequately responsive to methotrexate.

I am certainly going to try this and assess for myself in clinical practice whether the triple-therapy approach is equivalent to what I have experienced when starting patients on TNF inhibitors. Thank you for joining me in this Medscape report at the 2013 EULAR Congress of Rheumatology in Madrid. I'm Dr. Jonathan Kay.


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