I read with interest the article by Burmester et al1 on the efficacy and safety of ascending methotrexate (MTX) dose in combination with adalimumab. Increasing doses of oral at 2.5, 5, 10 or 20 mg weekly in combination with adalimumab demonstrated a statistically significant trend in improved clinical outcomes in early rheumatoid arthritis (RA) patients but efficacy of 10 and 20 mg/week MTX in combination with adalimumab therapy appeared equivalent. The authors suggest because of patient-reported treatment satisfaction, clinical efficacy and pharmacokinetics for patients initiating adalimumab combination therapy, the optimal starting dose may be lower than previously assumed; the treating physicians may consider 10 mg of MTX a week when deciding which dose of MTX to choose in conjunction with antitumour necrosis factor (anti-TNF) therapy and this presents an opportunity to lower MTX dosage in patients with RA.

Several reasons may militate against generalising this suggestion based on the …