Background Methotrexate(MTX) is recommended as the first DMARD in rheumatoid arthritis (RA) at a weekly dose of 20-25mg in combination with folic acid supplementation. Despite its widespread use and more than two decades of experience, considerable variations exist among rheumatologists in prescribing MTX.
Objectives To describe symptomatic and structural impact of the MTX optimization in early arthritis (EA) in daily clinical practice over 2 years.
Methods - Patients: from the French cohort of EA ESPOIR (at least 2 swollen joints for less than 6 months and suspicion of RA), fulfilling the new ACR-EULAR criteria for RA at baseline, and treated by MTX as first DMARD.
- Treatment group: optimized MTX was defined by at least 3 months of MTX during the first 6 months and dose of initiation at least 10 mg/week with escalation at 6 months at least at 20 mg/w or 0.3mg/kg/w if DAS28>2.6
- Outcomes: remissions (Boolean, SDAI and DAS28), functional stability (HAQ≤0.5 and deltaHAQ≤0.25) and absence of radiographic progression (delta Sharp score<1).
- Analyses: evaluation of the symptomatic and structural efficacy has been performed by generalized linear regression after adjustement on propensity score (by modelling the optimization of MTX by disease specific- and demographic variables obtained at baseline, using logistic regression analysis) in the group of patients receiving optimized MTX versus the ones receiving MTX without optimization.
Results Within the first year of follow-up of 600 RA patients, 352 received MTX as first DMARD. The mean dose of MTX was 13.1 +/- 3.9 mg/week. In all, 76.1% of patients received at least 3 months of MTX during the first 6 months and 25.3% were treated initially at least by 10 mg/week with escalation at 6 months at least at 20 mg/w or 0.3mg/kg/w if DAS28>2.6; only 22.1% fulfilled the 2 criteria. MTX optimization was initiated in younger patients (45.2 years ± 12.6 vs 49.3 ± 11.3, p=0.009) with higher CRP (29.3±32.0 vs 24.4±36.7, p=0.006). After adjustment, optimized MTX was found to be more efficient in terms of remission and function than control (table).
Conclusions Optimized MTX is more efficacious on remission and function than MTX without optimization in EA in daily practice but without impact on radiographic progression over 2 years.
Disclosure of Interest C. Gaujoux-Viala Grant/research support from: Pfizer, Nordic Pharma, S. Paternotte: None Declared, B. Combe: None Declared, M. Dougados: None Declared, B. Fautrel Grant/research support from: Roche, Pfizer, Nordic Pharma, MSD
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