title: Combination conventional DMARDs compared to biologicals: what is the evidence?
abstract: OBJECTIVE
  Dramatic improvement seen in the prognosis of rheumatoid arthritis has been driven by higher expectations, led by newer drugs and more intensive use of the older drugs. Although methotrexate has retained its place as the first-line agent, there has been great interest in comparing biologicals to conventional Disease Modifying Anti Rheumatic Drugs (DMARDs) over the past few years with the updated guidelines from both the American College of Rheumatology and European League Against Rheumatism. We have tried to critically summarize the findings of some landmark trials that compare these two approaches.
  
  
  RESULTS
  Treatment of Early Rheumatoid Arthritis, The Swedish Pharmacotherapy study and Rheumatoid Arthritis Comparison of Active Therapies are landmark trials that were designed to compare strategies using biologicals vs. conventional DMARDs. We will review the safety and efficacy data from these three trials here and also briefly the important cost differential.
  
  
  CONCLUSIONS
  Methotrexate should be the first-line therapy for most rheumatoid arthritis patients and will produce the desired results in greater than one-third of the patients. When methotrexate is not adequate, triple DMARD therapy should be added which will result in control of approximately another one-third of the patients. Ultimately, and usually before 1 year of disease, the remainder of patients will require biological therapies usually added to conventional DMARDs. There is no evidence that this step-up approach results in any long-term disadvantage and good evidence that it results in substantial cost savings.
authors.affiliation: University of Nebraska Medical Center, Omaha, Nebraska, USA.
authors.forename: Manpreet K
authors.initials: MK
authors.lastname: Sethi
authors.forename: James R
authors.initials: JR
authors.lastname: O'Dell
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000188:drug therapy*; D001688:Biological Products / Q000627:therapeutic use*; D018450:Disease Progression; D004359:Drug Therapy, Combination; D006801:Humans; D008727:Methotrexate / Q000627:therapeutic use; D011859:Radiography; D016032:Randomized Controlled Trials as Topic
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D008727:Methotrexate