Combination Treatment Works Best for Preventing Future Complications

Oct. 28, 2005 -- Two or even three drugs are much better than one in treating the early stages of rheumatoid arthritis and preventing future complications, according to a new study.

Dutch researchers compared the four most recommended and widely used prescription drug treatments for early rheumatoid arthritis (RA). The researchers found that people treated with a combination therapy with methotrexate (sold under Rheumatex and other brand names), and corticosteroids or Remicade (infliximab) fared much better one year later than those treated with methotrexate alone.

Researchers say two new classes of drugs, known as disease-modifying antirheumatic drugs (DMARDs) and tumor necrosis factor (TNF) antagonists, have changed the way rheumatoid arthritis is treated in recent years. Used early on, studies have shown that these drugs have the potential to slow the progression of rheumatoid arthritisrheumatoid arthritis and reduce joint damage.

But the best strategy and combinations for using the drugs to prevent long-term joint damage and disability is unclear.

Rheumatoid Arthritis Treatments Face Off

In the study, researchers compared the effectiveness of the four most widely prescribed drug treatments for early rheumatoid arthritis in 508 people, mostly women, over the course of one year. Participants were ones with early RA who had the disease for two years or less and who had not had prior treatment with DMARDs. Other criteria for inclusion and exclusion of participants were based on history of medical conditions, lab tests, and substance abuse.

The participants were divided into four groups and received one of the following four treatments:

1. Standard DMARD therapy: methotrexate alone.
2. Step-up combination therapy: methotrexate alone to start followed by adding other DMARDs and prednisone.
3. Combination therapy with three drugs: methotrexate, Azulfidine, and taper high-dose prednisone.
4. Combination therapy with two drugs: methotrexate and Remicade.

At the end of the study, researchers used X-rays to measure joint damage and disease progression as well as clinical exams to evaluate symptom improvement.

Patients With Best Results

Patients With Best Results

The results showed that each treatment group showed measurable improvements, and 32% of all participants experienced a remission of their disease.

But those who received initial combination therapy with methotrexate and Remicade or prednisone had significantly less joint damage and progression of their disease than those treated with methotrexate alone or those in the step-up combination group.

"Patients in groups 3 and 4 had the benefit of a more rapid relief of symptoms and improvement of physical function," says researcher B. A. C. Dijkmans, MD, of VU Medical Center in Amsterdam, The Netherlands, in a news release. "In addition, there is the possibility that effective suppression of disease activity during the early phases of the disease may ameliorate the long-term joint damage and poor physical function and, ideally, even induce true clinical remission without the need for ongoing DMARD treatment."

The number of rheumatoid arthritis patients in these two groups without any progression of their disease was also higher than in the other two groups.

Overall, researchers say people who received initial combination rheumatoid arthritis treatment experienced no more side effects than the other groups.

Methotrexate can cause severe toxicity to the liver and bone marrow. Regular monitoring of blood counts and liver enzymes is standard during treatment. Methotrexate can also produce injury to the lungs and the GI tract. Pregnant women and those that are planning on being pregnant should not take this medication.

Remicade use has been associated with severe liver injury, decreased blood counts, and development of lymphoma (a kind of cancer). It should not be used if you are suffering from certain other medical conditions.

Both medications have immune-suppressing activity which can make a person more susceptible to infections, particularly opportunistic infections that can be fatal.