Induction therapy with a combination of DMARDs is better than methotrexate monotherapy: first results of the tREACH trial.
OBJECTIVE
To determine the most effective induction disease-modifying antirheumatic drug (DMARD) strategy in early rheumatoid arthritis (RA), second to compare one single dose of intramuscular glucocorticoids (GCs) with daily oral GCs during the induction phase.


METHODS
The 3-month data of a single-blinded clinical trial in patients with recent-onset arthritis (tREACH) were used. Patients were included who had a high probability (>70%) of progressing to persistent arthritis, based on the prediction model of Visser. Patients were randomised into three induction therapy strategies: (A) combination therapy (methotrexate (MTX) + sulfasalazine + hydroxychloroquine) with GCs intramuscularly; (B) combination therapy with an oral GC tapering scheme and (C) MTX with oral GCs similar to B. A total of 281 patients were randomly assigned to strategy (A) (n=91), (B) (n=93) or (C) (n=97).


RESULTS
The Disease Activity Score (DAS) after 3 months was lower in patients receiving initial combination therapy than in those receiving MTX monotherapy (0.39 (0.67 to 0.11, 95% CI)). DAS did not differ between the different GC bridging treatments. After 3 months 50% fewer biological agents were prescribed in the combination therapy groups. Although the proportion of patients with medication adjustments differed significantly between the treatment arms, no differences were seen in these adjustments due to adverse events after stratification for drug.


CONCLUSIONS
Triple DMARD induction therapy is better than MTX monotherapy in early RA. Furthermore, no differences were seen in medication adjustments due to adverse events after stratification for drug. Intramuscular and oral GCs are equally effective as bridging treatments and both can be used.
Department of Rheumatology, University Medical Center, ErasmusMC, Rotterdam, Netherlands. p.h.p.dejong@erasmusmc.nl
P H
PH
de Jong
J M
JM
Hazes
P J
PJ
Barendregt
M
M
Huisman
D
D
van Zeben
P A
PA
van der Lubbe
A H
AH
Gerards
M H
MH
de Jager
P B
PB
de Sonnaville
B A
BA
Grillet
J J
JJ
Luime
A E
AE
Weel
D000284:Administration, Oral; D018501:Antirheumatic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage; D006801:Humans; D006886:Hydroxychloroquine / Q000008:administration & dosage / Q000009:adverse effects; D060828:Induction Chemotherapy; D007273:Injections, Intramuscular; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D020127:Recovery of Function / Q000187:drug effects; D012460:Sulfasalazine / Q000008:administration & dosage / Q000009:adverse effects
D018501:Antirheumatic Agents; D005938:Glucocorticoids; D012460:Sulfasalazine; D006886:Hydroxychloroquine; D008727:Methotrexate