Background For patients with rheumatoid arthritis (RA) who have an inadequate response to methotrexate (MTX), there is some uncertainty about the relative effectiveness of combination of conventional DMARDs compared with combination of TNF inhibitors and MTX, as second line therapy.

Objectives To compare efficacy and tolerance of triple oral DMARD therapy versus anti-TNF associated with MTX in patients with RA after MTX failure.

Methods A systematic search of literature up to Mars 2014 was performed, in Medline, Embase, the Cochrane library and abstracts from the ACR and EULAR congresses from 2006 to 2013. Studies were included if they were randomised and controlled trial in patients receiving a triple oral combination therapy (MTX + sulfasalasine + hydroxychloroquine) compared with biologic agents plus methotrexate. Treatment effects on disease activity (DAS 28), American College of Rheumatology and the European League Against Rheumatism response criteria and structural damage using Sharp score were studied.

Results Our search identified 263 articles, among them only 5 responded to the selection criteria. At six months and two years, there is a significantly larger number of participants achieving an ACR 70 response in the anti-TNF group. At one year, a significantly higher percentage of patients in the anti-TNF group reached a good EULAR response. Patients treated with TT have a significantly greater increase in modified Sharp than patients treated with MTX-infliximab at two years.

Analysis based on ACR-EULAR response criteria, the DAS 28 score and Sharp score were in favor of anti-TNF combined with MTX. There was no difference between treatments on functional disability (HAQ) and rates of adverse events.

Conclusions In patients with RA in whom MTX has failed, addition of tumour necrosis factor antagonist to MTX is a valid option with better clinical outcomes and better radiographical results. Addition treatment with DMARDs is an appropriate treatment option in the absence of poor prognostic factors and/or in case of TNF inhibitors contraindications in a health-economic restreint context.

Disclosure of Interest None declared