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Discussion of recent JCR articles, PANLAR issues, controversies, and special areas of interest. We encourage readers of JCR, as well as PANLAR members, to participate and extend the dialogue.

Thursday, August 15, 2013

Lets consider triple DMARDs for RA

I had editorialized recently about whether we are paying enough attention to the value of oral, inexpensive triple DMARDs for our patients with RA1. Since then this new report from O’Dell et al in the NEJM adds further support to the value of triple DMARDs as comparable to the biologic etanercept plus methotrexate2.  Unfortunately an accompanying editorial asks “we have to consider, however, whether these findings have arrived too late to influence modern practice, in which arguably a TNF inhibitor is the preferred next step when methotrexate alone is inadequate”3.  Is it really too late for us to consider the cost of health care as a concern of ours?  At the recent EULAR congress Strand noted that the CORRONA registry data is showing that after two years 58% of patients given a biologic had discontinued it.  Isn’t it time to not just automatically go to a biologic without giving triple DMARDs a try?   

1 Schumacher HR.  Are we being open enough to all approaches to therapy of rheumatoid arthritis?  J Clin Rheumatol. 2013;19:167-71.

2 O'Dell JR, Mikuls TR, Taylor TH, Ahluwalia V, Brophy M, Warren SR, Lew RA, Cannella AC, Kunkel G, Phibbs CS, Anis AH, Leatherman S, Keystone E; CSP 551 RACAT Investigators.  Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013;369:307-18.

3 Bathon JM, McMahon DJ. Making rational treatment decisions in rheumatoid arthritis when methotrexate fails. N Engl J Med. 2013;369:384-5.