Support for combining non-methotrexate csDMARDs with biologics in RA patients
medwireNews: Non-methotrexate conventional synthetic (cs)DMARDs may be “efficient alternatives” to methotrexate for using in combination with biologics for the treatment of rheumatoid arthritis (RA), researchers report.
These findings are based on a meta-analysis of 21 studies investigating the use of methotrexate versus alternative csDMARDs alongside biologic therapy. Tumor necrosis factor (TNF) inhibitors were the most commonly used biologic (n=13 studies), followed by rituximab (n=5) and abatacept (n=3).
Among patients treated with TNF inhibitors, those given concomitant non-methotrexate csDMARDs – most commonly leflunomide – were significantly less likely to achieve a good or moderate EULAR response at 6 months than those given methotrexate, but “the difference was modest,” report Claire Daien (CHU Montpellier and Montpellier University, France) and co-investigators.
Indeed, 72% of 681 patients treated with alternative csDMARDs and 76% of 3162 given methotrexate achieved this outcome (risk ratio [RR]=0.93), while average DAS28 score improved by 0.29 points more in the methotrexate group. Rates of serious adverse events were significantly higher in the alternative csDMARD group (10 vs 6%; RR=1.63).
On the other hand, use of non-methotrexate csDMARDs was associated with better outcomes among patients treated with rituximab; analysis of five studies showed that patients treated with this combination had a significant 30% higher likelihood of achieving a good EULAR response relative to those given methotrexate with rituximab. In the three studies where leflunomide was the alternative csDMARD, leflunomide use was associated with a significant 38% higher chance of achieving a good EULAR response. Serious adverse event rates were comparable among patients receiving alternative csDMARDs versus methotrexate.
Methotrexate “is thus a good option to use when possible in association with TNF [inhibitors],” whereas leflunomide “seemed superior to [methotrexate] when combined with [rituximab],” write Daien and team in Arthritis Care & Research.
They note that methotrexate and alternative csDMARDs had comparable efficacy and safety profiles when used in combination with abatacept.
The researchers also attempted to investigate the impact of different csDMARDs when used in combination with tocilizumab or Janus kinase inhibitors, but they say that insufficient data were available to draw conclusions.
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