Session Type: ACR Concurrent Abstract Session
Session Time: 9:00AM-10:30AM
Optimal treatment for moderate-severe early rheumatoid arthritis involves using a methotrexate-based, treat-to-target strategy aiming for remission. Achieving remission without using biologics may be preferable due to their high cost and potential risk of infection. However, it is still unknown which initial treatment strategy is preferable. Our objective was to compare effects of initial treatment with MTX oral monotherapy, MTX subcutaneous (sc) monotherapy, and MTX combination therapy on time to first use of biologic DMARDs in a large national early RA cohort.
Data were obtained from a multi-center prospective cohort study of patients with early RA. The present analysis included participants who met 1987 or 2010 ACR criteria for RA, with <12 months symptom duration, moderate or high disease activity based on the DAS28 at baseline and treated with MTX. Patients treated with a biologic at baseline were excluded. Patients were followed until they started a biologic or they were censored due to loss to follow up or the end of the 3-year study period. Cox proportional hazards survival analysis was used to estimate effects of oral MTX monotherapy, sc MTX monotherapy, and MTX combination therapy adjusting for age, gender, education level, symptom duration, comorbidities, baseline erosions, baseline DAS28, and corticosteroid use. Logistic regression analysis was used to determine predictors of ever vs. never biologic use.
Results: 1189 patients were included and 212 first events of biologic use. At baseline, 865 (71%) were female with mean (sd) age of 54 (15) years, symptom duration 6 (3) months, and DAS28 of 5.45 (1.2). Oral MTX monotherapy was used as initial treatment in 230 (20%), sc MTX monotherapy in 226 (20%), and MTX combination therapy in 664 (60%). In fully adjusted Cox regression models, patients treated with subcutaneous MTX monotherapy had a significantly delayed time to first biologic use (HR = 0.53, p = 0.02). There was no difference between MTX combination therapy and oral MTX monotherapy (HR = 0.95). In logistic regression models of ever vs. never biologic use, there were no significant differences between treatment strategies. Predictors of biologic use included younger age, use of corticosteroids, longer symptom duration, and higher baseline DAS28.
Treatment with sc MTX monotherapy was associated with a delayed time to biologics. This may be due to increased treatment efficacy compared to oral MTX. Combination DMARD therapy was not associated with longer time to biologic initiation, potentially due to provincial regulations requiring a trial of combination DMARD therapy before initiating biologics. This study suggests that early use of sc MTX can potentially delay the need for more expensive biologic therapies.
To cite this abstract in AMA style:Gottheil S, Thorne JC, Schieir O, Boire G, Haraoui B, Hitchon C, Tin D, Barnabe C, Hazlewood G, Keystone E, Bykerk VP, Pope JE, Bartlett SJ. “Early Use of Subcutaneous MTX Monotherapy Vs. MTX Oral or Combination Therapy Significantly Delays Time to Initiating Biologics in Early RA [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). http://acrabstracts.org/abstract/early-use-of-subcutaneous-mtx-monotherapy-vs-mtx-oral-or-combination-therapy-significantly-delays-time-to-initiating-biologics-in-early-ra/. Accessed August 24, 2017.
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