Background/Purpose: Current treatment guidelines for rheumatoid arthritis (RA) recommend a treat-to-target approach with early treatment initiation of disease-modifying antirheumatic drugs (DMARDs), most commonly methotrexate (MTX), and treatment escalation in case of insufficient response. In this scenario, similar efficacy of biological DMARDs (bDMARDs)  + MTX compared to conventional triple therapy (MTX + sulfasalazine + hydroxychloroquine) has been shown in randomized control trials. We aimed to compare occurrences of occasional and sustained remission in patients receiving triple therapy versus bDMARDs + MTX as first treatment strategy after MTX monotherapy, using real-life data from the Swedish national Rheumatology Quality Register (SRQ).

Methods: Adult patients with a clinical diagnosis of RA registered in the SRQ between 2000/01/01 and 2012/12/31 receiving triple therapy or any bDMARD + MTX as first treatment strategy after MTX monotherapy were included. ACR 1987 criteria were satisfied by 96.8% of patients. Occasional remission was defined as a disease activity score with 28 joint counts with erythrocyte sedimentation rate (DAS28) < 2.6 at one occasion and sustained remission as remission for ≥6 months. Per protocol analyses were used for occasional and sustained remission achieved during treatment at 12 and 24 months (during), and intention to treat analyses were used for occasional and sustained remission achieved at any time in the follow-up (ever). Propensity score adjusted regression analyses were performed.

Results: In total, 347 patients receiving triple therapy and 1156 patients receiving a bDMARD + MTX were included. Crude Kaplan Meier analyses of proportions of patients achieving occasional and sustained remission ever showed no statistically significant differences between triple therapy and bDMARDs + MTX (Figure). Propensity score adjusted odds ratios (ORs) (biological/triple therapy) with 95% confidence intervals (CIs) for occasional remission during treatment at 12 and 24 months were 1.38 (95% CI 0.90-2.11) and 1.51 (95% CI 0.87-2.60) respectively. For sustained remission during treatment at 12 and 24 months, ORs were 1.34 (95% CI 0.86-2.10) and 1.22 (95% CI 0.70-2.14) respectively. For occasional and sustained remission ever, hazard ratios were 1.13 (95% CI 0.96-1.33) and 1.12 (95% CI 0.91-1.38) respectively.

Conclusion: In this nationwide Swedish register study, we found no statistically significant differences between triple therapy and bDMARDs + MTX as first treatment strategy after MTX monotherapy in odds of achieving occasional and sustained remission during treatment at 12 and 24 months, or ever in the follow-up. This suggests that in RA, conventional triple therapy is a good alternative to bDMARDs + MTX.

Crude_KaplanMeier

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/remission-in-patients-with-rheumatoid-arthritis-receiving-triple-therapy-compared-to-biological-therapy-a-swedish-nationwide-register-study/