Re: REVIEW - The efficacy and toxicity of MTX monotherapy versus MTX combination therapy with non-biologic DMARDs in RA

[Guest guest]

This seems to indicate we're better off using one medication or the other, since

I currently on MTX (just got a dose inscrease) and although I don't like it, it

does seem to be effective. However, my Rheumatologist favors combining

treatments. She also very much favors not being told what to do, so much so that

I am considering getting a second opinion from another Rheumatologist. Has

anyone else done this?

Thanks,

Stan

-------------- Original message --------------

From: " " <Rheumatoid.Arthritis.Support@...>

Ann Rheum Dis. Published Online First: 3 December 2008.

doi:10.1136/ard.2008.099861

----------------------------------------------------------

Extended Report

The efficacy and toxicity of Methotrexate (MTX) monotherapy vs. MTX

combination therapy with non-biologic disease-modifying anti-rheumatic

drugs in rheumatoid arthritis: A systematic review and metaanalysis

Wanruchada Katchamart 1, Judith Trudeau 2, Veerapong Phumethum 1 and

Bombardier 3*

1 University of Toronto, Canada

2 Hospital Notre-Dame, Department of Rheumatology, Canada

3 Institute for Work and Health, Canada

Abstract

Objective: To evaluate the efficacy and toxicity of Methotrexate (MTX)

monotherapy compared to MTX combination with non-biologic

disease-modifying anti-rheumatic drugs (DMARDs) in adult with

rheumatoid arthritis.

Method: We performed a systematic review of randomized trials

comparing MTX alone and in combination with other non-biologic DMARDs.

Trials were identified in MEDLINE, EMBASE, the Cochrane Library and

ACR/EULAR meeting abstracts. Primary outcomes were withdrawals for

adverse events or lack of efficacy.

Results: A total of 19 trials (2,025 patients) from 6,938 citations

were grouped by the type of patients randomized. Trials in DMARD naive

patients showed no significant advantage of the MTX combination versus

monotherapy; withdrawals for lack of efficacy or toxicity were similar

in both groups (Relative Risk: RR 1.16, 95% CI.0.70-1.93). Trials in

MTX or non MTX DMARDs inadequate responder patients, also showed no

difference in withdrawal rates between the MTX combo vs mono groups

(RR 0.86; 95% CI 0.49 to1.51 and RR 0.75; 95% CI 0.41 to 1.35) but in

one study the specific combination of MTX with sulfasalazine and

hydroxychloroquine showed better efficacy/ toxicity ratio over MTX

alone with RR of 0.3 (95%CI 0.14 to 0.65). Adding leflunomide to MTX

non-responders improved efficacy but increased the risk of

gastrointestinal side effect and liver toxicity. Withdrawals for

toxicity were most significant with cyclosporine and azathioprine

combinations.

Conclusion: In DMARD naive patients the balance of efficacy/toxicity

favours MTX monotherapy. In DMARD inadequate responders the evidence

is inconclusive. Trials are needed that compare currently used MTX

doses and combination therapies.

http://ard.bmj.com/cgi/content/abstract/ard.2008.099861v1?papetoc

Not an MD

[Guest guest]

Hi Stan, I met with 3 before settling on the rheum for me:

#1 I liked as a person, but she was very confusing/incoherent, liked jabbing my

knee with needles, and wanted to do sulfa drugs only. She also botched my

diagnosis (said I didn't have RA, forgot to run the antiCCP, and then never came

out and said " you have RA " rather she said " your labs were positive so we have

to be more aggressive " .  It wasn't until I got my own copies of my labs that I

saw " dx RA " written down.  Crummy patient care, I'd say)

#2 recommended Enbrel + pred but was retiring in a year

#3 was just right!  Agreed with #2s plan and managed me until we relocated.

After the move, I sought out 2 rheums and settled on the 2nd.  This is a

lifelong disease and it's well worth it to find someone you feel comfy with and

supported by. 

Kate F

________________________________

From: " stanpfister@... " <stanpfister@...>

Sent: Thursday, December 4, 2008 11:41:28 AM

Subject: Re: [ ] REVIEW - The efficacy and toxicity of MTX monotherapy

versus MTX combination therapy with non-biologic DMARDs in RA

This seems to indicate we're better off using one medication or the other, since

I currently on MTX (just got a dose inscrease) and although I don't like it, it

does seem to be effective. However, my Rheumatologist favors combining

treatments. She also very much favors not being told what to do, so much so that

I am considering getting a second opinion from another Rheumatologist. Has

anyone else done this?

Thanks,

Stan

------------ -- Original message ------------ --

From: " " <Rheumatoid.Arthriti s.Support@ gmail.com>

Ann Rheum Dis. Published Online First: 3 December 2008.

doi:10.1136/ ard.2008. 099861

------------ --------- --------- --------- --------- --------- -

Extended Report

The efficacy and toxicity of Methotrexate (MTX) monotherapy vs. MTX

combination therapy with non-biologic disease-modifying anti-rheumatic

drugs in rheumatoid arthritis: A systematic review and metaanalysis

Wanruchada Katchamart 1, Judith Trudeau 2, Veerapong Phumethum 1 and

Bombardier 3*

1 University of Toronto, Canada

2 Hospital Notre-Dame, Department of Rheumatology, Canada

3 Institute for Work and Health, Canada

Abstract

Objective: To evaluate the efficacy and toxicity of Methotrexate (MTX)

monotherapy compared to MTX combination with non-biologic

disease-modifying anti-rheumatic drugs (DMARDs) in adult with

rheumatoid arthritis.

Method: We performed a systematic review of randomized trials

comparing MTX alone and in combination with other non-biologic DMARDs.

Trials were identified in MEDLINE, EMBASE, the Cochrane Library and

ACR/EULAR meeting abstracts. Primary outcomes were withdrawals for

adverse events or lack of efficacy.

Results: A total of 19 trials (2,025 patients) from 6,938 citations

were grouped by the type of patients randomized. Trials in DMARD naive

patients showed no significant advantage of the MTX combination versus

monotherapy; withdrawals for lack of efficacy or toxicity were similar

in both groups (Relative Risk: RR 1.16, 95% CI.0.70-1.93) . Trials in

MTX or non MTX DMARDs inadequate responder patients, also showed no

difference in withdrawal rates between the MTX combo vs mono groups

(RR 0.86; 95% CI 0.49 to1.51 and RR 0.75; 95% CI 0.41 to 1.35) but in

one study the specific combination of MTX with sulfasalazine and

hydroxychloroquine showed better efficacy/ toxicity ratio over MTX

alone with RR of 0.3 (95%CI 0.14 to 0.65). Adding leflunomide to MTX

non-responders improved efficacy but increased the risk of

gastrointestinal side effect and liver toxicity. Withdrawals for

toxicity were most significant with cyclosporine and azathioprine

combinations.

Conclusion: In DMARD naive patients the balance of efficacy/toxicity

favours MTX monotherapy. In DMARD inadequate responders the evidence

is inconclusive. Trials are needed that compare currently used MTX

doses and combination therapies.

http://ard.bmj. com/cgi/content/ abstract/ ard.2008. 099861v1? papetoc

Not an MD

[Guest guest]

Stan, I went to another Rheumy for a second opinion and found out that I had

'no disability at all' and this is before he even touched me or asked a

question. He even decided that I didn't have RA either. It was a waste of

money and time.

Dennis in eastexas

On Thu, Dec 4, 2008 at 11:41 AM, <stanpfister@...> wrote:

> This seems to indicate we're better off using one medication or the

> other, since I currently on MTX (just got a dose inscrease) and although I

> don't like it, it does seem to be effective. However, my Rheumatologist

> favors combining treatments. She also very much favors not being told what

> to do, so much so that I am considering getting a second opinion from

> another Rheumatologist. Has anyone else done this?

>

> Thanks,

> Stan

>

>

> -------------- Original message --------------

> From: " "

<Rheumatoid.Arthritis.Support@...<Rheumatoid.Arthritis.Support%40gmail.com\

>>

>

> Ann Rheum Dis. Published Online First: 3 December 2008.

> doi:10.1136/ard.2008.099861

> ----------------------------------------------------------

> Extended Report

>

> The efficacy and toxicity of Methotrexate (MTX) monotherapy vs. MTX

> combination therapy with non-biologic disease-modifying anti-rheumatic

> drugs in rheumatoid arthritis: A systematic review and metaanalysis

>

> Wanruchada Katchamart 1, Judith Trudeau 2, Veerapong Phumethum 1 and

> Bombardier 3*

> 1 University of Toronto, Canada

> 2 Hospital Notre-Dame, Department of Rheumatology, Canada

> 3 Institute for Work and Health, Canada

>

> Abstract

>

> Objective: To evaluate the efficacy and toxicity of Methotrexate (MTX)

> monotherapy compared to MTX combination with non-biologic

> disease-modifying anti-rheumatic drugs (DMARDs) in adult with

> rheumatoid arthritis.

>

> Method: We performed a systematic review of randomized trials

> comparing MTX alone and in combination with other non-biologic DMARDs.

> Trials were identified in MEDLINE, EMBASE, the Cochrane Library and

> ACR/EULAR meeting abstracts. Primary outcomes were withdrawals for

> adverse events or lack of efficacy.

>

> Results: A total of 19 trials (2,025 patients) from 6,938 citations

> were grouped by the type of patients randomized. Trials in DMARD naive

> patients showed no significant advantage of the MTX combination versus

> monotherapy; withdrawals for lack of efficacy or toxicity were similar

> in both groups (Relative Risk: RR 1.16, 95% CI.0.70-1.93). Trials in

> MTX or non MTX DMARDs inadequate responder patients, also showed no

> difference in withdrawal rates between the MTX combo vs mono groups

> (RR 0.86; 95% CI 0.49 to1.51 and RR 0.75; 95% CI 0.41 to 1.35) but in

> one study the specific combination of MTX with sulfasalazine and

> hydroxychloroquine showed better efficacy/ toxicity ratio over MTX

> alone with RR of 0.3 (95%CI 0.14 to 0.65). Adding leflunomide to MTX

> non-responders improved efficacy but increased the risk of

> gastrointestinal side effect and liver toxicity. Withdrawals for

> toxicity were most significant with cyclosporine and azathioprine

> combinations.

>

> Conclusion: In DMARD naive patients the balance of efficacy/toxicity

> favours MTX monotherapy. In DMARD inadequate responders the evidence

> is inconclusive. Trials are needed that compare currently used MTX

> doses and combination therapies.

>

> http://ard.bmj.com/cgi/content/abstract/ard.2008.099861v1?papetoc

>

>

> Not an MD

>

>

[Guest guest]

I'm speechless! I would have expected exactly the opposite!

Stan

-------------- Original message --------------

From: " Dennis W " <betnden@...>

Stan, I went to another Rheumy for a second opinion and found out that I had

'no disability at all' and this is before he even touched me or asked a

question. He even decided that I didn't have RA either. It was a waste of

money and time.

Dennis in eastexas

On Thu, Dec 4, 2008 at 11:41 AM, <stanpfister@...> wrote:

> This seems to indicate we're better off using one medication or the

> other, since I currently on MTX (just got a dose inscrease) and although I

> don't like it, it does seem to be effective. However, my Rheumatologist

> favors combining treatments. She also very much favors not being told what

> to do, so much so that I am considering getting a second opinion from

> another Rheumatologist. Has anyone else done this?

>

> Thanks,

> Stan

>

>

> -------------- Original message --------------

> From: " "

<Rheumatoid.Arthritis.Support@...<Rheumatoid.Arthritis.Support%40gmail.com\

>>

>

> Ann Rheum Dis. Published Online First: 3 December 2008.

> doi:10.1136/ard.2008.099861

> ----------------------------------------------------------

> Extended Report

>

> The efficacy and toxicity of Methotrexate (MTX) monotherapy vs. MTX

> combination therapy with non-biologic disease-modifying anti-rheumatic

> drugs in rheumatoid arthritis: A systematic review and metaanalysis

>

> Wanruchada Katchamart 1, Judith Trudeau 2, Veerapong Phumethum 1 and

> Bombardier 3*

> 1 University of Toronto, Canada

> 2 Hospital Notre-Dame, Department of Rheumatology, Canada

> 3 Institute for Work and Health, Canada

>

> Abstract

>

> Objective: To evaluate the efficacy and toxicity of Methotrexate (MTX)

> monotherapy compared to MTX combination with non-biologic

> disease-modifying anti-rheumatic drugs (DMARDs) in adult with

> rheumatoid arthritis.

>

> Method: We performed a systematic review of randomized trials

> comparing MTX alone and in combination with other non-biologic DMARDs.

> Trials were identified in MEDLINE, EMBASE, the Cochrane Library and

> ACR/EULAR meeting abstracts. Primary outcomes were withdrawals for

> adverse events or lack of efficacy.

>

> Results: A total of 19 trials (2,025 patients) from 6,938 citations

> were grouped by the type of patients randomized. Trials in DMARD naive

> patients showed no significant advantage of the MTX combination versus

> monotherapy; withdrawals for lack of efficacy or toxicity were similar

> in both groups (Relative Risk: RR 1.16, 95% CI.0.70-1.93). Trials in

> MTX or non MTX DMARDs inadequate responder patients, also showed no

> difference in withdrawal rates between the MTX combo vs mono groups

> (RR 0.86; 95% CI 0.49 to1.51 and RR 0.75; 95% CI 0.41 to 1.35) but in

> one study the specific combination of MTX with sulfasalazine and

> hydroxychloroquine showed better efficacy/ toxicity ratio over MTX

> alone with RR of 0.3 (95%CI 0.14 to 0.65). Adding leflunomide to MTX

> non-responders improved efficacy but increased the risk of

> gastrointestinal side effect and liver toxicity. Withdrawals for

> toxicity were most significant with cyclosporine and azathioprine

> combinations.

>

> Conclusion: In DMARD naive patients the balance of efficacy/toxicity

> favours MTX monotherapy. In DMARD inadequate responders the evidence

> is inconclusive. Trials are needed that compare currently used MTX

> doses and combination therapies.

>

> http://ard.bmj.com/cgi/content/abstract/ard.2008.099861v1?papetoc

>

>

> Not an MD

>

>

[Guest guest]

One time I had to go to another GP because mine was out for a while. He

didn't look at me either before looking at me but announced that I had a

'regular' flu bug. He also told me that if he were my doctor, I wouldn't be

on disability. He never put a hand on me, either.

I did find out that Medicare is getting me a new power chair soon, but not

for the damage to my body from RA, it's from my heart 'problems'. I can't

use a scooter because of the torn bicep muscle, and it takes 2 hands to

operate it.

Dennis in eastexas

On Thu, Dec 4, 2008 at 9:25 PM, <stanpfister@...> wrote:

> I'm speechless! I would have expected exactly the opposite!

>

> Stan

>

>

> -------------- Original message --------------

> From: " Dennis W " <betnden@... <betnden%40gmail.com>>

> Stan, I went to another Rheumy for a second opinion and found out that I

> had

> 'no disability at all' and this is before he even touched me or asked a

> question. He even decided that I didn't have RA either. It was a waste of

> money and time.

>

> Dennis in eastexas

>

> On Thu, Dec 4, 2008 at 11:41 AM,

<stanpfister@...<stanpfister%40comcast.net>>

> wrote:

>

> > This seems to indicate we're better off using one medication or the

> > other, since I currently on MTX (just got a dose inscrease) and although

> I

> > don't like it, it does seem to be effective. However, my Rheumatologist

> > favors combining treatments. She also very much favors not being told

> what

> > to do, so much so that I am considering getting a second opinion from

> > another Rheumatologist. Has anyone else done this?

> >

> > Thanks,

> > Stan

> >

> .

>

>

>

[Guest guest]

Hi, Stan.

In this review, the authors concluded that, in patients who hadn't

tried any DMARDs yet, MTX alone seemed to best thing to use in terms

of safety and efficacy. In those who used one of the various

traditional DMARDs and had an inadequate response, they couldn't tell

if it is better to move to another monotherapy or combination therapy

instead.

Keep in mind they weren't discussing any of the biologic DMARDs.

If you don't really like your current rheumatologist, please look for another.

Not an MD

On Thu, Dec 4, 2008 at 11:41 AM, <stanpfister@...> wrote:

> This seems to indicate we're better off using one medication or the other,

> since I currently on MTX (just got a dose inscrease) and although I don't

> like it, it does seem to be effective. However, my Rheumatologist favors

> combining treatments. She also very much favors not being told what to do,

> so much so that I am considering getting a second opinion from another

> Rheumatologist. Has anyone else done this?

>

> Thanks,

> Stan