Methotrexate combined with a TNF-inhibitor slows joint damage more than methotrexate alone

This study examined whether a combination of methotrexate and tumor-necrosis factor inhibitors was more effective in treatment of rheumatoid arthritis than methotrexate alone.

Rheumatoid arthritis is a chronic (long-term) disease, therefore the focus of treatment is to prevent joint damage and slow the progression of the disease. The earlier treatment is begun the more benefit the patient sees. The first-line (primary) treatment for the majority of rheumatoid arthritis patients is methotrexate (Trexall), a disease-modifying antirheumatic drug. For patients who do not respond to this treatment, tumor-necrosis factor (TNF) inhibitors, such as adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade), are the next treatment. TNF is a protein that can cause inflammation.

The combination of methotrexate and TNF-inhibitors has been shown in clinical trials to slow joint destruction, even when there does not appear to be a benefit to symptoms such as joint pain and swelling. The current study examined whether the slowed joint destruction seen in controlled trials is also seen in actual practice, with a variety of patients.

This trial included 84 patients: 49 received methotrexate alone and 35 received methotrexate plus a TNF-inhibitor. Patient symptom response was evaluated with the Disease Activity Score 28, a measure of disease activity in 28 joints, at months 0, 3, 6, 9, and 12. X-rays were used to measure joint damage progression at the start of the study and at month 12.

No significant differences in disease symptoms were seen between the two groups, though there was a trend towards decreased symptoms in patients receiving both methotrexate and a TNF-inhibitor. An equal percentage (30.6% for methotrexate alone, 31.4% for methotrexate plus TNF-inhibitor) achieved Disease ActivityScore 28 remission (no disease activity) at 12 months.

Joint damage progression as seen by x-ray was seen in a significantly higher number (81.6%) of methotrexate alone patients, compared to 45.7% of patients receiving both methotrexate and a TNF-inhibitor. For patients who were only receiving methotrexate and who did not show any improvement in symptoms, increased joint damage was seen on x-rays compared to patients who did see an improvement in symptoms. This difference between those with and without symptoms was not seen in the joint damage of patients receiving both methotrexate and a TNF-inhibitor.

This study concluded that the combination of methotrexate and a tumor-necrosis inhibitor slowed joint damage more effectively than did methotrexate alone, even when disease symptoms had not shown improvement.