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Methotrexate Long-Time Favourite Rheumatoid Arthritis Therapy

A long-term comparison of more than 1,300 consecutive courses of disease-modifying anti-rheumatic drugs (DMARDs) has found methotrexate traditionally the most commonly used for rheumatoid arthritis (RA).

Moreover, this agent came to be used increasingly as first therapy in newly diagnosed RA, report Drs D Aletaha and J S Smolen from the University of Vienna and Lainz Hospital, Vienna, Austria.

Sequential use of DMARDs is typical RA therapy. Authors of this single-centre study sought to reveal the changing patterns of use of traditional DMARDs over two decades before newer ones emerged.

Researchers followed 593 RA patients from their first clinic visit through the course of their disease, analysing more than 2,300 patient years of therapy for efficacy and duration of consecutive DMARDs therapy. Of the 593 patients, 222 received their first such therapy at this clinic.

Prior to 1985, between 65 percent and 90 percent of initial DMARDs were gold compounds. However, their use decreased continuously after that.

While antimalarial (AM) drugs were important initial DMARDs in new patients at all times, sulphasalazine (SSZ) and methotrexate (MTX) gained increasing significance after 1985. Indeed, the first DMARD was MTX in up to 29 percent of new patients.

Penicillamine (DPA), azathioprine (AZP), cyclosporin (CyA) and combination therapies were not used initially, but rather were reserved for the later course of the disease.

This investigation found there were no gender, age or rheumatoid factor differences among patients receiving different DMARDs.

However, baseline acute-phase response was higher in patients treated with MTX versus SSZ or AM, suggesting MTX was used preferentially in patients with high disease activity, the authors note. On the other hand, once AM or SSZ had been discontinued, MTX was the most common subsequent DMARD.

Comparison of first DMARDs with subsequent ones indicates first DMARDs were more effective: the acute-phase response decreased most prominently during first therapies, and retention rates were significantly longer for first versus subsequent therapies (median of 24.5 months for first and 18.6 months for fourth or subsequent therapies). Thus, MTX was most commonly used and was used increasingly as first therapy in new RA.

While patients with high disease activity were given MTX therapy more often than other DMARDs, those with low activity were more likely to receive SSZ or AM and MTX on failure of these drugs.

Finally, first DMARDs in new patients were retained longer than subsequent DMARDs, evidently because they are more effective, these authors conclude.
Rheumatology (Oxford) 2002;41(12):1367-74. "The rheumatoid arthritis patient in the clinic: comparing more than 1300 consecutive DMARD courses."

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