For patients with rheumatoid arthritis (RA) where methotrexate therapy has failed, adding a tumor necrosis factor (TNF) antagonist may help achieve improved clinical outcomes and radiographic results if poor prognosis factors are present. The findings from this systematic review are published in The Journal of Rheumatology.

In order to investigate second-line therapy options for RA patients with methotrexate failure, researchers from Montpellier University, France, conducted a systematic literature search to compare the efficacy and tolerance of triple oral DMARD therapy vs anti-TNF drugs plus methotrexate.

Study articles were included if they were randomized controlled trials of patients receiving triple oral combination therapy (methotrexate + sulfasalazine + hydroxychloroquine [TT])  vs. anti-TNF agents + methotrexate. 

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The treatment effects were examined by disease activity (DAS28), ACR and EULAR response criteria, structural damage by the modified total Sharp score, and functional disability by the Health Assessment Questionnaire (HAQ).  

A total of 263 articles were identified, of which five met the inclusion criteria. The data overall showed favorable ACR and EULAR response criteria, DAS28, and modified Sharp scores with anti-TNF agents + methotrexate. 

There was no difference with HAQ and rates of adverse events between the treatment groups. 

In the presence of poor prognostic factors, adding an anti-TNF agent to methotrexate “may be a valid option” for patients with RA after methotrexate failure. 

If there are no poor prognostic factors and/or contraindications to biologics, triple oral combination therapy (TT) “retains its place in the therapeutic strategy for RA in a currently restricted economic context,” concluded study author Julia Mary.

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Mary J, De bandt M, Lukas C, Morel J, Combe B. Triple oral therapy versus antitumor necrosis factor plus methotrexate (MTX) in patients with rheumatoid arthritis and inadequate response to MTX: A systematic literature review [published online April 15, 2017]  J Rheumatol. doi: 10.3899/jrheum.160643

This article originally appeared on MPR