Biologic vs Methotrexate

Current rheumatoid arthritis (RA) treatment guidelines generally suggest starting with a traditional disease-modifying anti-rheumatic drug (DMARD) such as methotrexate, and escalating therapy from there if necessary. But research has shown that fewer than half of RA patients reach remission with methotrexate alone. That begs the question: Would it make sense to turn to a biologic drug, such as a TNF inhibitor, sooner?

Some studies have suggested that more patients would benefit from starting with a combination of methotrexate and a TNF inhibitor from the time of an RA diagnosis, but new research is casting doubt on that idea. The study, which was published in the journal Annals of the Rheumatic Diseases, split 120 recently diagnosed RA patients into two groups and followed them for 48 weeks. One group took only took methotrexate; the other took methotrexate as well as etanercept (Enbrel), which is a TNF inhibitor biologic.

At the end of the study, patients in the etanercept/methotrexate group did tend to fare better, but the distinction was less impressive than the authors were expecting. Based on previous research on the topic, the researchers had anticipated that 70 percent of the etanercept/methotrexate group and 40 percent of the methotrexate group would reach remission, but that’s not what happened.

Instead, 52 percent of those incorporating etanercept achieved remission, as did 38 percent of those in the methotrexate only group. That’s only a 14-point difference between the groups (and they were expecting a 30-point difference).

The authors noted that more research is required to determine whether new patients should be encouraged to use a TNF inhibitor along with methotrexate as soon as they’re diagnosed.

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Keep Reading

Chatzidionysiou K, et al. Low rates of remission with methotrexate monotherapy in rheumatoid arthritis: review of randomised controlled trials could point towards a paradigm shift. RMD Open. June 2019. doi:

Emery P, et al. Pragmatic randomised controlled trial of very early etanercept and MTX versus MTX with delayed etanercept in RA: the VEDERA trial. Annals of the Rheumatic Diseases. January 2020. doi:

Singh JA, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis & Rheumatology. January 2016. doi:

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