Treatment Strategies in Early Rheumatoid Arthritis Methotrexate Management: Results From a Prospective Cohort

Abstract

on behalf of the Canadian Early Arthritis Cohort InvestigatorsObjective. To assess real-world practice patterns surrounding treatment initiation and adjustments over time for methotrexate (MTX) and non-MTX-based treatment strategies in early rheumatoid arthritis (RA).Methods. We studied a multicenter, incident early RA cohort (enrolled 2007-2017 within 1 year of symptoms) who fulfilled American College of Rheumatology/European League Against Rheumatism criteria. Adult patients with RA were eligible if treatment with MTX (± other disease-modifying antirheumatic drugs [DMARDs]) was initiated within 90 days of cohort entry. We compared time until treatment change for 4 initial MTX-based therapies and time to second treatment change after the first change. The definition of treatment change included changing of route for MTX monotherapy, adding or stopping a DMARD or biologic, and changing dose/frequency of a DMARD or biologic.Results. There was great variability of treatment at initiation and during therapy adjustment. In 1,484 patients with early RA, the majority initiated MTX monotherapy (oral or subcutaneous [SC]). Patients receiving SC MTX monotherapy changed treatment less (45% versus 79%) and remained on treatment longer (hazard ratio [HR] 0.52 [95% confidence interval (95% CI) 0.4-0.67]) than those receiving oral MTX monotherapy. Most therapy adjustments involved adding a DMARD or changing to a non-MTX DMARD. Those adults taking biologics and who were receiving triple therapy had a longer time without treatment change (HR 0.26 [95% CI 0.16-0.42] and HR 0.57 [95% CI 0.38-0.85], respectively). Conclusion.We found large variability in the way MTX-based therapies are prescribed in clinical practice. Our findings support the use of SC MTX monotherapy or MTX combination as initial therapy. For subsequent treatment after initial MTX-based therapy, those patients initiating either biologics or triple therapy had a longer time to treatment change than oral MTX monotherapy.

Chinese Registry of Rheumatoid Arthritis (CREDIT) VI: Temporal Trends in Patients With Early Rheumatoid Arthritis and Moderate‐To‐Severe Disease Activity ‐ A Multicenter Cohort Study of Treatment Strategies and Outcomes

“…Both the ACR and EULAR guidelines recommend incorporating a bDMARD or tsDMARD into the initial csDMARD treatment strategy if the therapeutic target is not achieved and poor prognostic factors are present [6, 7]. Notably, in Period B, the prescription rate for b/tsDMARDs following csDMARD failure increased, surpassing the rate reported in an earlier Canadian cohort (6.74%) [37]; nevertheless, a significant number of patients did not undergo treatment escalation, indicating suboptimal adherence to the guidelines. The prescription rate of JAKi as an escalated treatment option increased markedly, exceeding that of TNFi in Period B.…”

Methotrexate in Italian patients wiTh Rheumatoid Arthritis (MITRA study): an observational study about the use of methotrexate in early RA patients and the adherence to the EULAR 2013 recommendations. A project of the Italian Society for Rheumatology

“…In most cases the drug was prescribed as a monotherapy: this could depend on the fact than Italian rheumatologists can start a biologic treatment after the failure of a single DMARD or based on the evidence of a higher risk of toxicity during a combined DMARDs therapy (39,40). Many countries tend to prefer an oral administration of MTX (41,42) while in our population a subcutaneous route was selected in 94.3% of patients, in line with the evidence that a parenteral administration is more effective and better tolerated (43,44).…”

Methotrexate injection: An old drug with a newly developing landscape

“…A multicenter cohort study conducted in Canada in 2022 showed that subcutaneous injection was significantly superior to oral administration in single‐agent MTX treatment of early RA. The use of MTX as the initial medication for early RA also significantly reduced the use of biological disease‐modifying antirheumatic drugs (DMARDs), thereby contributing to healthcare cost savings 9 . Dermatological studies have also revealed that subcutaneous injection of MTX is significantly superior to oral administration in the treatment of severe psoriasis 10 .…”