Prescribing Patterns for Methotrexate in RA Deemed 'Too Little, Too Late'

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Prescribing Patterns for Methotrexate in RA Deemed 'Too Little, Too Late'

By Karla Gale

NEW YORK (Reuters Health) Nov 06 - According to a novel " therapeutic segment

approach " used to study response to treatment with methotrexate (MTX) for

rheumatoid arthritis (RA), treatment tends to be suboptimal in clinical

practice.

Dr. F. Fries, and associates at the Stanford University School of

Medicine, defined the MTX therapeutic segment as the " period that begins

with start of MTX and terminates when MTX is discontinued or another disease

modifying antirheumatic drug is added. " The Palo Alto, California-based

researchers maintain that theirs is a " potentially illuminating approach to

the analysis of treatment decisions. "

They studied 437 patients drawn from eight Arthritis, Rheumatism, and Aging

Medical Information System (ARAMIS) data centers who initiated MTX treatment

between 1988 and 1996. The Disability Index of the Health Assessment

Questionnaire was prospectively determined every 6 months.

Overall, Dr. Fries' group found a pattern of MTX treatment for RA that was

" too little, too late, and too long to treatment change. "

Average patient disability improved and then leveled off at about 30 to 42

months, after which disability began to increase again. Disability index

scores averaged 1.48 (on a scale of 0 to 3) at baseline, with a nadir of

1.23 at about 30 months. The mean score was 1.39 at 84 months. Eight or more

years elapsed before disability returned to baseline levels.

This protracted response, according to the research team's report in the

Journal of Rheumatology for October, " suggests that dosage titration of MTX

may have been slower than desirable and that some therapeutic benefit may

thereby have been lost. "

" I think this situation is still true today, " Dr. Fries told Reuters Health.

" On one hand, academic researchers recommend that MTX be prescribed at 15 or

17.5 or as much as 22.5 mg/week. In practice it's more like 10 mg/week. "

" We have all been concerned with liver fibrosis, but that's not really much

of a problem; it's a process that takes years, " the researcher added. " So

physicians should titrate the dose to a predetermined maximum within 6

months based on a patient's size and other medications or to toxicity. "

" When MTX is used aggressively, we get results that are not so different "

from those achieved with the newest therapeutic agents for RA, Dr. Fries

continued, " and the cost is only a fraction. "

In an accompanying editorial, Dr. H. Giannini, of the University of

Cincinnati College of Medicine in Ohio, writes that the therapeutic segment

approach " should be considered a major addition to the methodological tools

available to the field of evidence-based medical and clinical effectiveness

research. "

He maintains that the conclusions and recommendations by Dr. Fries' team are

valid.

J Rheumatol 2002;29:2084-2091.