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Induction therapy with a combination of DMARDs is better than methotrexate monotherapy: first results of the tREACH trial
  1. P H de Jong1,
  2. J M Hazes1,
  3. P J Barendregt2,
  4. M Huisman3,
  5. D van Zeben3,
  6. P A van der Lubbe4,
  7. A H Gerards4,
  8. M H de Jager5,
  9. P B de Sonnaville6,
  10. B A Grillet7,
  11. J J Luime1,
  12. A E Weel1,2
  1. 1Department of Rheumatology, University Medical Center, Rotterdam, Netherlands
  2. 2Department of Rheumatology, Maasstad Hospital, Rotterdam, Netherlands
  3. 3Department of Rheumatology, Sint Francicus Gasthuis Hospital, Rotterdam, Netherlands
  4. 4Department of Rheumatology, Vlietland Hospital, Schiedam, Netherlands
  5. 5Department of Rheumatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
  6. 6Department of Rheumatology, Admiraal de Ruyter Hospital, Goes, Netherlands
  7. 7Department of Rheumatology, Zorgsaam Hospital, Terneuzen, Netherlands
  1. Correspondence toPascal Hendrik Pieter de Jong, Department of Rheumatology, University Medical Center, ErasmusMC, Room Ee963a, Postbus 2040, 3000CA Rotterdam, Netherlands; p.h.p.dejong{at}


Objective To determine the most effective induction disease-modifying antirheumatic drug (DMARD) strategy in early rheumatoid arthritis (RA), second to compare one single dose of intramuscular glucocorticoids (GCs) with daily oral GCs during the induction phase.

Methods The 3-month data of a single-blinded clinical trial in patients with recent-onset arthritis (tREACH) were used. Patients were included who had a high probability (>70%) of progressing to persistent arthritis, based on the prediction model of Visser. Patients were randomised into three induction therapy strategies: (A) combination therapy (methotrexate (MTX) + sulfasalazine + hydroxychloroquine) with GCs intramuscularly; (B) combination therapy with an oral GC tapering scheme and (C) MTX with oral GCs similar to B. A total of 281 patients were randomly assigned to strategy (A) (n=91), (B) (n=93) or (C) (n=97).

Results The Disease Activity Score (DAS) after 3 months was lower in patients receiving initial combination therapy than in those receiving MTX monotherapy (0.39 (0.67 to 0.11, 95% CI)). DAS did not differ between the different GC bridging treatments. After 3 months 50% fewer biological agents were prescribed in the combination therapy groups. Although the proportion of patients with medication adjustments differed significantly between the treatment arms, no differences were seen in these adjustments due to adverse events after stratification for drug.

Conclusion Triple DMARD induction therapy is better than MTX monotherapy in early RA. Furthermore, no differences were seen in medication adjustments due to adverse events after stratification for drug. Intramuscular and oral GCs are equally effective as bridging treatments and both can be used.

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  • Competing interests None.

  • Funding Unrestricted grant from Pfizer bv. (0881–102217).

  • Provenance and peer review Not commissioned; externally peer reviewed.