Patients with rheumatoid arthritis who discontinued methotrexate monotherapy were more likely to receive subsequent monotherapy treatment than those who had used the drug in combination with other disease-modifying anti-rheumatic drugs, according to findings published in Clinical and Experimental Rheumatology.
The researchers also found that the new treatment was often delayed.
“This study is important as it shows an unexpected practice trend of many patients are not receiving their next treatment in a timely fashion,” Janet E. Pope, MD, of the University of Western Ontario, in London, Ontario, Canada, told Healio Rheumatology. “The proportion of patients not receiving another DMARD post [methotrexate] is surprisingly high. This has also been found after major CV events, that patients with RA and psoriatic arthritis are less likely to receive another treatment for their diseases.”
To evaluate treatment practices among individuals with RA, and determine how regimens are selected after methotrexate is discontinued, the researchers conducted a sub-study of participants in the Ontario Best Practices Research Initiative (OBRI), an observational registry of patients with RA who have at least one swollen joint at multiple sites in Ontario. The researchers focused their analysis on biologic-naive patients who discontinued methotrexate due to lack of effect, intolerability or other adverse events.
Among the 313 participants who stopped methotrexate, 102 were receiving it as monotherapy, with 156 on double and 55 on multiple conventional synthetic DMARDs. In total, 54% of patients transitioned to, or added, new DMARDs following discontinuation, whereas 46% received no new treatment.
According to the researchers, patients who had received methotrexate in combination with other DMARDs were more likely to switch to new conventional or biologic DMARDs, compared with those initially treated with monotherapy. The presence of early RA (OR = 3.07; 95% CI, 1.4-6.72) and receiving multiple DMARDs (OR = 4.15; 95% CI, 1.35-12.8), as opposed to methotrexate only, were both predictors of adding new treatments after stopping methotrexate.
“Up to half the RA patients who stop methotrexate for reasons of failure or intolerance or adverse events do not take another DMARD during several months of follow up,” Pope said. “This is less likely if patients have earlier disease or are on combination therapy when the methotrexate is changed.”
According to Pope, more research is needed to determine why the patients with monotherapy are not receiving another treatment when they are not in sustained remission.
“Patient preferences may have to be studied to determine why this is occurring, especially in established RA, as there may be fear of another drug giving side effects, or a lack of hope,” she said. “I also think that if we are aware that stopping or failing methotrexate is a risk for no RA treatment, especially in those on monotherapy or with established RA, then we will need to see the patients frequently after an adverse event, or treatment failure, to ensure patients have proper utilization of other treatments.” – by Jason Laday