Ann Rheum Dis 1999;58:220-225 ( April )

Extended reports

Combination therapy in early rheumatoid arthritis: a randomised, controlled, double blind 52 week clinical trial of sulphasalazine and methotrexate compared with the single components Maxime Dougados, Bernard Combe, Alain Cantagrel, Philippe Goupille, Patrick Olive, Manfred Schattenkirchner, S Meusser, L Paimela, Rolf Rau, Henning Zeidler, Marjatta Leirisalo-Repo, Kristiina Peldan

Correspondence to: Dr M Dougados, Institut de Rhumatologie, Hardy B, Hôpital Cochin, 27 rue du Fg Saint-Jacques, 75014 Paris, France.

Accepted for publication 4 November 1998

OBJECTIVESTo investigate the potential clinical benefit of a combination therapy.
METHODS205 patients fulfilling the ACR criteria for rheumatoid arthritis (RA), not treated with disease modifying anti-rheumatoid drugs previously, with an early (1 year duration), active (Disease Activity Score (DAS) > 3.0), rheumatoid factor and/or HLA DR 1/4 positive disease were randomised between sulphasalazine (SASP) 2000 (maximum 3000) mg daily (n = 68), or methotrexate (MTX) 7.5 (maximum 15) mg weekly (n = 69) or the combination (SASP + MTX) of both (n = 68).
RESULTSThe mean changes in the DAS during the one year follow up of the study was 1.15, 0.87, 1.26 in the SASP, MTX, and SASP + MTX group respectively (p = 0.019). However, there was no statistically significant difference in terms of either EULAR good responders 34%, 38%, 38% or ACR criteria responders 59%, 59%, 65% in the SASP, MTX, and SASP + MTX group respectively. Radiological progression evaluated by the modified Sharp score was very modest in the three groups: mean changes in erosion score: +2.4, +2.4, +1.9, in narrowing score: +2.3, +2.1, +1.6 and in total damage score: +4.6, +4.5, +3.5, in the SASP, MTX, and SASP + MTX groups respectively. Adverse events occurred more frequently in the SASP + MTX group 91% versus 75% in the SASP and MTX group (p = 0.025). Nausea was the most frequent side effect: 32%, 23%, 49% in the SASP, MTX, and SASP + MTX groups respectively (p = 0.007).
CONCLUSIONThis study suggests that an early initiation therapy of disease modifying drug seems to be of benefit. However, this study was unable to demonstrate a clinically relevant superiority of the combination therapy although several outcomes were in favour of this observation. The tolerability of the three treatment modalities seems acceptable.

Keywords: rheumatoid arthritis; combination therapy; sulphasalazine; methotrexate

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© 1999 by Annals of the Rheumatic Diseases
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