Single DMARD Use May Be As Effective As, Safer Than Combination Therapy for Rheumatoid Arthritis

When it comes to rheumatoid arthritis, early treatment is key. As a progressive disease with no known cure, it's crucial to begin the process of curbing progression, relieving inflammation and limiting joint damage from the start. Unfortunately, one of the primary therapies used for this condition comes with several side effects and is not effective for some patients.

The medications commonly used for patients with rheumatoid arthritis are called disease-modifying antirheumatic drugs (DMARDs). These drugs work by suppressing the immune system. In people with this condition, it is believed that the immune system malfunctions, misidentifying joint tissue as a harmful invader and attacking it. Over time, inflammation and joint wear can lead to disability.

There are several different types of DMARDs, each with its own set of side effects and risks. Methotrexate is the most popular; it's associated with adverse events ranging from upset stomach and rash to liver toxicity and bone marrow toxicity (and birth defects when used by pregnant women). Another common medication, sulfasalazine, has its own very long list, ranging in severity from nausea and tiredness to liver damage, nerve/muscle problems and infections. A third commonly-used DMARD, leflunomide, is associated with symptoms from diarrhea, runny nose and skin rash to signs of a serious reaction, including troubled breathing, fever and uneven heartbeat. (These are not complete lists of side effects.)

Despite risks, the American College of Rheumatology guidelines for the treatment of early arthritis recommend the use of combination therapy - treatment with two or three DMARDs in conjunction. Because severe side effects aren't common and the risk associated with the progression of rheumatoid arthritis are serious, this is considered to be better than reduced medication therapy at the outset.

However, a new study out of Belgium calls into question those recommendations, although more research is needed to overhaul current thinking around the condition's treatment. In the study, 290 high-risk early rheumatic patients were randomized into one of three treatment groups: methotrexate combined with sulfasalazine and a high initial dose of steroids (group 1); methotrexate with leflunomide and a moderate initial steroid dose (group 2); and methotrexate alone with a moderate initial steroid dose (group 3). Researchers monitored patients for disease remission and adverse events after 16 weeks of treatment.

All three treatment groups yielded similar remission rates - around 70% of patients qualified for remission status (it should be noted that this rate is high compared to previous research). However, adverse event rates varied significantly. In group 1 (combination sulfasalazine therapy), 61.2% reported some adverse event, and 69.1% in group 2 (combined leflunomide therapy) reported side effects. However, only 46.9% in the single DMARD group did so.

While nearly half of patients in a treatment group reporting side effects is nothing to sneeze at, the similar rates of remission compared to the different rates of side effects between groups stands in support of single DMARD use. Of course, more research is needed to validate these results. However, the results are promising for the many rheumatic patients who will be in search of the safest, most effective treatment path possible.