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Early treatment with infliximab an option for RA

Using tumour necrosis factor inhibitors for patients with recentlydiagnosed rheumatoid arthritis who have not responded to methotrexatehas been given a boost with the publication of new data

Using tumour necrosis factor inhibitors for patients with recently diagnosed rheumatoid arthritis who have not responded to methotrexate has been given a boost with the publication of new data in The Lancet (2009;374:459).

In the Swedish study (known as Swefot), 258 patients who had not achieved an effect after three to four months’ treatment with methotrexate were randomised to receive (in addition to methotrexate) either TNF inhibitor infliximab or disease-modifying antirheumatic drugs sulfasalzine and hydroxychloroquine (replaced with ciclosporin if poorly tolerated).

More patients receiving infliximab achieved a good response at 12 months (according to European League Against Rheumatism criteria; the primary outcome) than did those receiving sulfasalazine/ hydroxychloroquine (39% vs 25%; P=0.016).

“The Swefot trial provides yet more data on the effectiveness of anti-TNF agents, particularly when methotrexate monotherapy has failed,” commented Richard Copeland, rheumatology pharmacist practitioner at Northumbria Healthcare NHS Trust.

However, Mr Copeland questioned some of the study’s findings: “Its conclusion that, in patients who have failed methotrexate monotherapy, addition of an anti-TNF is superior to addition of conventional DMARDs is not entirely justified. For example, doses of up to 25mg/week of methotrexate are often used in UK practice, whereas the maximum dose used in this trial was 20mg.”

Furthermore, Mr Copeland pointed out that the trial protocol permitted “occasional” use of intra-articular corticosteroid injections, rather than as per the TICORA study (Lancet 2004;364:263), which used steroids as frequently as required to achieve tight disease control.

“Combinations of sulfasalazine and hydroxychloroquine, added to methotrexate, seemed reasonable, but the alternative option of using ciclosporin did not, as this agent is rarely used in clinical practice, certainly in the UK,” he told Clinical Pharmacist.

Mr Copeland drew attention to an ongoing trial (known as TACIT) that, he said, aims to compare intensive combination therapy, using a range of options, against anti-TNF treatment. “This practical approach may yield more meaningful data,” he suggested.

“Overall, the current evidence still points to early and aggressive treatment with DMARDs and steroids as required, moving on rapidly to using biologic treatments when these approaches do not achieve the desired results.”

Citation: Clinical Pharmacist URI: 10977384

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