Methotrexate Superior to Sulfasalazine as First-Line csDMARD Monotherapy in Patients With PsA

A flare-up of psoriasis on a man's hands
A flare-up of psoriasis on a man’s hands
Researchers evaluated drug retention and predictors for drug retention among patients with psoriatic arthritis receiving first-line conventional synthetic DMARD monotherapy.

Methotrexate outperforms sulfasalazine as a first-line conventional synthetic disease-modifying antirheumatic drug (csDMARD) with regard to monotherapy drug retention in psoriatic arthritis (PsA) treatment, according to study results published in Rheumatology.

Researchers performed a retrospective cohort study of DMARD-naive patients with PsA to assess csDMARD efficacy by evaluating monotherapy drug retention. The main outcome was first-time csDMARD retention time. A total of 187 patients who received either methotrexate (n=163) or sulfasalazine (n=21) were included in the study. Of the patients included in the cohort, 68% were men. Disease duration was 0.4 years for PsA and 7.5 years for psoriasis. A total of 87% of patients received methotrexate, 11% received sulfasalazine, and 2% received leflunomide. The main differences between the groups were that patients who received methotrexate were older and had a higher body mass index and swollen joint count and those who received the other drugs. Patients who received methotrexate were also more likely to have erosive disease than those who received sulfasalazine.

Overall median drug retention time was 31.8 months (interquartile range, 9.04-110 months). At the 1 year, 72% of patients who were initiated with methotrexate and 52% of those who were initiated with sulfasalazine were still using them as monotherapy, respectively. Results showed that the csDMARD used for treatment had a significant association with drug retention time. Patients who received methotrexate vs sulfasalazine showed significantly higher retention (median retention, 34.5 vs 12.0 months, respectively; P =.016). Higher age and the use of methotrexate was associated with increased monotherapy retention. A total of 11 patients who received methotrexate vs 2 who received sulfasalazine had remission.

Researchers indicated that methotrexate compared with sulfasalazine showed higher monotherapy retention. Older age was identified as a predictor of drug retention, confirming results described in a previous study. No other patient factors were found to be significantly associated with retention time. Based on these findings, methotrexate was shown to outperform sulfasalazine as a monotherapy drug in DMARD-naive patients.

Study limitations included its retrospective nature, the small number of patients who received sulfasalazine vs methotrexate, and the influence of certain factors in the daily lives of patients with drug retention.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Jacobs ME, Pouw JN, Welsing P, Radstake TRDJ, Leijten EFA. First-line csDMARD monotherapy drug retention in psoriatic arthritis: methotrexate outperforms sulfasalazine. Published online August 14, 2020. Rheumatology. doi:10.1093/rheumatology/keaa399