The inflammation of rheumatoid arthritis can cause permanent joint damage and disability. A review provided by Dr. Ferdinand C. Breedveld and Dr. Bernard Combe of Leiden University Medical Center in The Netherlands recommends more intensive, combination therapy early in the course of the disease.
Based on several clinical trials, Breedveld and Combe concluded, “a window of opportunity may exist whereby therapeutic intervention could have a disproportionate impact on outcome, resulting in remission induction and maintenance of response after cessation of treatment.”
Currently there is no treatment that is considered a cure for rheumatoid arthritis, but drug-free remission is an ideal outcome. The first step, according to Breedveld and Combe, is to identify which patients have rapidly progressing disease.
For these patients, drug-free remission may be more readily achieved with early combination therapy. A biologic TNF(tumor necrosis factor) inhibitor plus a disease modifying anti-rheumatic drug (DMARD), usually methotrexate, may produce better results than either drug alone.
Studies supporting combination therapy include:
1. Combination of Methotrexate and Etanercept in Active Early Rheumatoid Arthritis. In this study, 50 percent of patients achieved clinical remission at 52 weeks of treatment with methotrexate plus etanercept, compared to 28 percent on methotrexate monotherapy.
2. PREMIER. Combination therapy with methotrexate and adalimumab produced clinical remission in 43 percent of patients, compared to 23 percent on adalimumab monotherapy and 21 percent on methotrexate monotherapy.
3. (Unnamed study). Combination methotrexate and infliximab produced better results than methotrexate monotherapy in patients with early rheumatoid arthritis and a poor prognosis, based on the Presistent Inflammatory Symmetrical Arthritis scoring system.
4. BeSt. This study investigated four treatment strategies: sequential monotherapy, step-up combination therapy, initial combination therapy with tapered high-dose prednisone, and initial combination therapy with infliximab. The two strategies with initial combination therapy produced the best results after one year.
The U.S. National Library of Medicine's PubMed web site lists five biologic drugs that may benefit arthritis patients:
1. Abatacept (brand name Orencia)
2. Adalimumab (brand name Humira)
3. Etanercept (brand name Enbrel)
4. Infliximab (brand name Remicade)
5. Rituximab (brand name Rituxan)
Anakira is mentioned as another option that may improve symptoms, but not as well as the others. The site provides statistics on how many people improved on each drug when used alone, and how many discontinued because of side effects.
Breedveld and Combe reported that the most common reasons for discontinuing biologic TNF inhibitors are dyspnea (trouble breathing), urticaria (skin rash), and headache. Other risks include infections, lymphoma, and injection site reactions.
References:
1. Breedveld FC et al, “Understanding emerging treatment paradigms in rheumatoid arthritis”, Arthritis Research & Therapy 2011; 13(Suppl 1): S3. http://www.ncbi.nlm.nih.gov/pubmed/21624182
2. PubMed Health. Biologics for rheumatoid arthritis: an overview of Cochrane reviews. Web. Sept. 24, 2011.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014642/
Linda Fugate is a scientist and writer in Austin, Texas. She has a Ph.D. in Physics and an M.S. in Macromolecular Science and Engineering. Her background includes academic and industrial research in materials science. She currently writes song lyrics and health articles.
Reviewed October 6, 2011
by Michele Blacksberg RN
Edited by Jody Smith