The updated ACR guidelines for the treatment of RA were recently published. They include newer drugs, and treatment philosophies such as treating to a target and reducing medications have been incorporated. I will applaud the group for all their work.
However, when are we going to actually follow the data that is proven in every single trial? Iinitial therapy with combination methotrexate (MTX) is always far superior to methotrexate monotherapy.
In every randomized clinical trial (RCT) in early, active, poor prognosis RA, MTX monotherapy is a failure 70% of the time, whereas MTX in combination with another conventional (or biologic) DMARD(s) is sufficient 70% of the time.
Over and over, triple therapy has been found to be superior to methotrexate monotherapy and some other traditional DMARD combinations at onset have not be studied as well. The first O’Dell triple DMARD trial from years ago, and the more recent TEAR and RACAT trials, have all shown triple therapy is superior to methotrexate monotherapy. Also any combination of MTX with biologics is better than MTX alone in those not exposed to methotrexate (such as TNFi’s, and some other advanced therapeutics).
So when I study the new treatment guidelines for early RA, those in low disease activity should be considered to be treated with DMARD monotherapy and surprisingly those with moderate or high disease activity are also recommended to have DMARD monotherapy. Why such recommendations despite all the data that always show MTX in combination is superior to MTX monotherapy in ERA with the odds of improvement (i.e. getting an ACR target response) are approximately 2 to 1 (combination vs. monotherapy)?
The only consideration of combination therapy is short-term corticosteroids for flare. Only after treatment failure with MTX monotherapy is there a suggestion of use of MTX combinations with traditional DMARD(s) or a biologic with or without methotrexate.
Where is the rationale that empowers such weak evidence while avoiding the strong? I am sure that some day treatment guidelines will reflect consistent RCT data and improve good clinical practice.