RESEARCH - Efficacy of initial MTX monotherapy versus combination therapy with a biologic in early RA

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Ann Rheum Dis 2010;69:1298-1304 doi:10.1136/ard.2009.118307

Clinical and epidemiological research

Extended report

Efficacy of initial methotrexate monotherapy versus combination

therapy with a biological agent in early rheumatoid arthritis: a

meta-analysis of clinical and radiographic remission

B Kuriya1,2, E V Arkema1, V P Bykerk2, E C Keystone2

+ Author Affiliations

1Harvard School of Public Health, Boston, Massachusetts, USA

2 Mac Centre for Arthritis and Autoimmune Diseases, Mount

Sinai Hospital, University of Toronto, Toronto, Canada

Abstract

Objective The target outcome in early rheumatoid arthritis (ERA) is

now remission. This meta-analysis compared the efficacy of initial

methotrexate monotherapy versus combination therapy (methotrexate plus

biological agent) for clinical remission and radiographic

non-progression among ERA patients with minimal or no previous

methotrexate exposure.

Methods A systematic search was performed for randomised controlled

trials of ERA using predefined criteria. A random effects model was

used to pool the risk ratio (RR) for clinical and radiographic

remission at 52–56 weeks of follow-up.

Results Seven trials of combination therapy with infliximab,

adalimumab, etanercept or abatacept were included. The majority of

studies defined clinical remission as a 28-joint disease activity

score (DAS28) of 2.6 or less. Radiographic non-progression was

primarily defined as a modified total Sharp score change of less than

0.5 units. All trials demonstrated risk estimates in favour of

combination therapy: the pooled RR for achieving clinical remission

was 1.74 (95% CI 1.54 to 1.98) and for radiographic non-progression

was 1.30 (95% CI 1.01 to 1.68). Significant heterogeneity among

studies for the latter outcome was detected (p<0.001).

Conclusions The efficacy of combination therapy with a biological

agent is superior to methotrexate monotherapy for remission.

Combination therapy has a greater initial effect on clinical remission

than radiographic non-progression. Uniform definitions of remission

are needed and the proportion of subjects who achieve the combined

endpoint of clinical and radiographic remission should be considered

as a meaningful outcome in future studies of ERA.

http://ard.bmj.com/content/69/7/1298.abstract?etoc

Not an MD