MADRID, Spain—Closer monitoring of rheumatoid arthritis (RA) patients and more aggressive use of methotrexate (MTX) contributed more to recent improvements in RA outcomes than did newer drugs such as TNF inhibitors, according to Spanish researchers.1

"It is probable that a better management of available drugs, mainly MTX, has been learned during the past decade along with the clinical development of most biologic agents, during which MTX has been used in a fast dose-escalation fashion."—Isidoro Gonzalez-Alvaro, MD
”It is probable that a better management of available drugs, mainly MTX, has been learned during the past decade along with the clinical development of most biologic agents, during which MTX has been used in a fast dose-escalation fashion. In addition, the systematic assessment of disease activity required in the EMECAR follow-up may have helped Spanish rheumatologists to realize that patients were not adequately controlled, thus leading to enhancement of patients' treatment,” said Isidoro Gonzalez-Alvaro, MD, reporting for the EMECAR (Estudio de la Morbilidad y Espresion Clinica de la Artritis Reumatoide) study group.

The EMECAR cohort was assembled in 2000 from 789 randomly selected RA patients registered in 34 tertiary centers in Spain. Each had a baseline assessment plus 4 annual follow-up visits. Outcome measures were the Health Assessment Questionnaire (HAQ) score, the disease activity score obtained from 28-joint count with 3 parameters (DAS28-3), and the Larsen score for radiological progression.

From 2000 to 2004 in these patients:
  • DAS28-3 improved by -0.43
  • HAQ increased by 0.15
  • Larsen score increased by 4.4
  • Treatment with either leflunomide (LEF) or TNF antagonists increased from 1.1% to 30.9%, following the 2001 approval of these drugs for use in Spain
  • LEF and TNF antagonists largely replaced antimalarials and gold salts for use in combinations with MTX
  • Median MTX dose increased from 7.5 mg/week to 12.5 mg/week

Dr. Gonzalez-Alvaro noted that in 1998 and 1999, 90% of all Spanish rheumatologists had never collected the variable needed to estimate the DAS28-3 during daily clinical practice. This was required during the EMECAR study.

“[T]he systematic assessment of disease activity they had to perform per protocol in EMECAR led the rheumatologists to realize the poor control they had over their own patients,” Dr. Gonzalez-Alvaro suggested. “On the other hand, the finding may also reflect the experience of rheumatologists in numerous aTNF clinical trials, where fast MTX dose escalation was the norm.”

Reference

1. Gonzalez-Alvaro, I, et al. Trends towards an improved disease state in rheumatoid arthritis over time: influence of new therapies and changes in management approach: analysis of the EMECAR cohort. Arthritis Research & Therapy (in press).