REVIEW - Have traditional DMARDs had their day? Effectiveness of parenteral gold vs. biologics.

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Clin Rheumatol. 2005 Jun;24(3):189-202. Epub 2004 Jul 24.

Have traditional DMARDs had their day? Effectiveness of parenteral gold

compared to biologic agents.

Rau R.

Department of Rheumatology, Evangelisches Fachkrankenhaus, Rosenstrasse 2,

40882, Ratingen, Germany. rrau@...

This review tries to answer the question of whether in the face of the

recently introduced biologics conventional disease-modifying antirheumatic

drugs (DMARDs) can still be recommended in the treatment of rheumatoid

arthritis (RA). We start with an overview of the oldest conventional DMARD,

injectable gold (Au), which was introduced in the treatment of RA in the

1920s. The effect of gold is directed at a number of different sites of the

immune system. A significant improvement of clinical and biochemical disease

activity parameters as well as an inhibition of X-ray progression has been

shown in many studies. Head-to-head comparisons between gold and high-dose

methotrexate (MTX) demonstrated no significant difference but some

advantages for gold. Since trials comparing biologics with gold will never

be performed, an indirect comparison was done by analyzing the results of

trials with gold with those with biologics. Conclusions from such

comparisons have to be drawn with caution especially since the methodology

for performing trials has changed with time. We selected four trials with

gold (two open, one placebo-controlled, and one comparison with MTX) and

five trials with biologics (three placebo-controlled, one dose escalation

study, and one comparison with MTX). In all these trials baseline data

regarding swollen joint count (SJC), erythrocyte sedimentation rate (ESR),

and C-reactive protein (CRP) were roughly comparable and, with the exception

of interleukin (IL)-1 RA, demonstrated a similar improvement of over 50%

already after 6 months [with faster onset with tumor necrosis factor

(TNF)-alpha blockade]. American College of Rheumatology (ACR) response data

were not available for the older gold trials. European League Against

Rheumatism (EULAR) response criteria could be calculated for the Au/MTX

trial and were-for these compounds-only slightly inferior to the results

with adalimumab. X-ray response is especially difficult to compare across

studies. Although an inhibition with Au and MTX could be demonstrated, this

occurred-similar to corticosteroid treatment-earlier and more pronounced

with TNF-alpha blockers. We confirm the statement of Weinblatt that the most

modern DMARDs do not appear to be much better than the oldest one indicating

that conventional DMARDs are not outdated. Therefore, a sufficient trial of

conventional DMARDs should precede the introduction of treatment with the

very expensive biologics.

PMID: 15940552

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

5940552 & dopt=Citation

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