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Cyclosporin A monotherapy versus cyclosporin A and methotrexate combination therapy in patients with early rheumatoid arthritis: a double blind randomised placebo controlled trial
  1. A H Gerards1,
  2. R B M Landewé2,
  3. A P A Prins1,
  4. G A W Bruijn3,
  5. H S Goei Thé2,
  6. R F J M Laan4,
  7. B A C Dijkmans1
  1. 1VU Medical Centre and Jan van Breemen Instituut, Amsterdam, The Netherlands
  2. 2University Hospital Maastricht, The Netherlands
  3. 3Medisch Centrum Leeuwarden, The Netherlands
  4. 4University Medical Centre St Radboud, Nijmegen, The Netherlands
  1. Correspondence to:
    Dr A H Gerards, Vlietland ziekenhuis, lokatie Schiedam, Burg Knappertlaan 25, 3116 BA Schiedam, The Netherlands;


Objective: To compare the efficacy and toxicity of cyclosporin A (CsA) monotherapy with CsA plus methotrexate (MTX) combination therapy in patients with early rheumatoid arthritis (RA).

Patients and methods: 120 patients with active RA, rheumatoid factor positive and/or erosive, were randomly allocated to receive CsA with MTX (n=60) or CsA with placebo (n=60). Treatment with CsA was started in all patients at 2.5 mg/kg/day and increased to a maximum of 5 mg/kg/day in 16 weeks. MTX was started at 7.5 mg/week and increased to a maximal dose of 15 mg/week at week 16. Primary outcomes were clinical remission (Pinals criteria) and radiological damage (Larsen score), at week 48.

Results: Treatment was discontinued prematurely in 27 patients in the monotherapy group (21 because of inefficacy, and six because of toxicity) and in 26 patients in the combination therapy group (14 and 12, respectively). At week 48, clinical remission was achieved in four patients in the monotherapy group and in six patients in the combination therapy group (p=0.5). The median Larsen score increased to 10 (25th, 75th centiles: 3.5; 13.3) points in the monotherapy group and to 4 (1.0; 10.5) points in the combination therapy group (p=0.004). 28/60 (47%) of patients in the monotherapy group v 34/60 (57%) of patients in the combination therapy group had reached an American college of Rheumatology 20% (ACR20) response (p=0.36) at week 48; 15/60 (25%) v 29/60 (48%) of patients had reached an ACR50 response (p=0.013); and 7 (12%) v 12 (20%) of patients had reached an ACR70 response (p=0.11).Their was a tendency towards more toxicity in the combination therapy group.

Conclusions: In patients with early RA, neither CsA plus MTX combination therapy nor CsA monotherapy is very effective in inducing clinical remission. Combination therapy is probably better at improving clinical disease activity, and definitely better at slowing radiological progression. Combination therapy should still be compared with methotrexate monotherapy.

  • cyclosporin A
  • early rheumatoid arthritis
  • randomised controlled trials
  • ACR, American College of Rheumatology
  • ALT, alanine aminotransferase
  • AST, aspartate aminotransferase
  • CRP, C reactive protein
  • CsA, cyclosporin A
  • DMARDs, disease modifying antirheumatic drugs
  • ESR, erythrocyte sedimentation rate
  • MTX, methotrexate
  • RA, rheumatoid arthritis
  • RCT, randomised controlled trial
  • VAS, visual analogue scale

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  • Correction
    BMJ Publishing Group Ltd and European League Against Rheumatism