I found info !

[Guest guest]

Hi . My email has been down since yesterday, so who knows when you will

get this. This article that was published in 1999 states that there are

doctors that prescribe 4 dmards. Not many, but it is done. I still feel

the same way, that in spite of your GI bleeding, it's a concern.

Disease Modifying Antirheumatic Drugs (DMARD) and DMARD Combination Use by

US Rheumatologists. 

F Wolfe, DJ Hawley, T Pincus Wichita, KS, Nashville, TN

The perception among rheumatologists is that more aggressive treatment of

rheumatoid arthritis (RA) will result in better outcomes.   Two possible

ways to assess ³aggressive treatment² are:  1) number of patients on DMARDs,

and 2) number of patients on combinations of DMARDs.  Data from 6,073

patients with RA were available from the National Data Bank for Rheumatic

Diseases established in 1998.   Patients were asked to self-report on

lifetime and current DMARD use, as well as current combination DMARD use.  

The average age of the patients was 59.7 years, average disease duration was

9.7 years, and 77% were women. 

93% of patients reported ever having been on a DMARD in the following

percentages: MTX 70%, hydroxychloroquine 53%, IM gold 34%, sulfasalazine

20%, auranofin 13.6%, azothioprine and D-penicillamine 10% each, leflunomide

6.1%, minocycline 6.0%; etanercept 4.7%, cyclosporine 3.9%; 68.4% of

patients were also receiving prednisone.   

76% reported currently receiving a DMARD:  MTX 48%, hydrochloroquine 26%, IM

gold 7.0%, leflunomide, azothioprine and etanercept 4.0% each, minocycline

2.8%, auranofin 2.7%, cyclosporine 1.6% ; 39.6 % were also receiving

prednisone.

Current combination DMARD use was reported as follows:   0 DMARDs, 26%; 1

DMARD, 49%; 2 DMARDs, 18.9%; 3 DMARDs, 4.3%; 4 DMARDs, 1.1%.   MTX +

hydroxychloroquine was by far the most common 2 drug combination, and MTX +

hydroxychloroquine + sulfasalazine the overwhelming choice for 3 drug

combination therapy. 

The authors conclude that combination DMARD therapy is still relatively

uncommon in the U.S., and that MTX is the most commonly used DMARD. 

Editorial comment: As Dr. Wolfe pointed out, these data reflect state of the

art practice in the U.S. before the newer agents (leflunomide and TNF

inhibitors) became widely available.  It will be interesting to see how the

use of DMARDs changes as more rheumatologists become familiar with the newer

agents, particularly as new data showing their disease modifying properties

evolves.  It is perhaps discouraging to see that only 50% of RA patients are

receiving even one DMARD. 

http://www.hopkins-arthritis.som.jhmi.edu/edu/college_of_rhuematology/ra-tre

atments-combination.html