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Methotrexate Replaces Sulphasalazine as Most Popular First-Choice Disease-Modifying Anti-Rheumatic Drug In UK

Methotrexate has displaced other disease-modifying anti- rheumatic drugs (DMARDs), especially sulphasalazine, as agent of first choice, and newer agents have displaced older DMARDs, according to a survey of British physicians.

Little has been known about the DMARD preferences of British rheumatologists. In a 1992 survey, sulphasalazine was the agent of first choice, but more recently, methotrexate has gained wide acceptance.

To assess the popularity of DMARDs, Paresh Jobanputra, MD, Department of Public Health and Epidemiology, University of Birmingham, United Kingdom, and colleagues mailed a questionnaire to 460 rheumatologists.

The researchers asked which DMARD(s) were preferred first, and which sequence or combination of DMARDs were used. The researchers also determined the extent to which prognostic and other factors influenced treatment choices.

After two mailings, 331 (72%) of 460 questionnaires were returned. The most popular sequence of DMARDs was methotrexate or sulphasalazine (singly or in combination), leflunomide, intramuscular gold and anti-tumour necrosis factor therapy.

Of the respondents, 95% preferred methotrexate (46.5%) or sulphasalazine (43.5%) or either of these two (5%) as first- choice agent. Of those who chose methotrexate first, 80% ranked sulphasalazine second, 45% combined sulphasalazine and methotrexate, and 49% then added hydroxychloroquine to this combination, in treating active disease.

Of those who chose sulphasalazine first, 95% ranked methotrexate second, with 75% preferring methotrexate monotherapy, and 12% preferring the combination with sulphasalazine. In addition, this group of respondents was more likely to use subsequent DMARDs as monotherapies than those who started with methotrexate (P<0.0001).

Leflunomide was more commonly preferred than intramuscular gold as third choice (P<0.003).

"Poor prognostic factors influenced DMARD choice, but patient occupation and drug costs did not," the researchers note.

Dr. Jobanputra and colleagues suggest that DMARD preference in the UK is broadly similar to current European practice, and "shows a greater predilection for sulphasalazine compared with the US."

"A growing preference for early methotrexate use may reflect increasing confidence in this drug, and may also be due to the greater likelihood for more prolonged drug use with methotrexate compared with other DMARDs," the team adds.
Rheumatology 2003 Aug 15;[Epub ahead of print].

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