Background EULAR recommends that all biologics DMARDs should be used preferentially in combination with methotrexate (MTX) in rheumatoid arthritis (RA) patients. The TEMPO study and the JESMR study showed that combination therapy with Etanercept (ETN) plus MTX was significantly superior to ETN alone in inhibiting radiographic progression of the hands, wrists, and forefeet [1, 2]. However, it is still unclear whether concomitant MTX affect inhibiting progression of large joint destruction in RA patients treated with ETN. Total joint replacement is a common procedure for damaged large joint, and it is the essential marker of severe joint destruction in RA patients .
Objectives The aim of this study was to investigate the effect of concomitant use of MTX on the incidence of large joint replacement surgery in RA patients treated with ETN.
Methods A retrospective multicenter study was performed by using Tsurumai Biologics Communication Registry (TBCR), which consisted of patients who were starting biologic treatments and included baseline characteristics. Of 652 RA patients treated with ETN, 42 patients underwent 58 total joint replacement (34 TKA, 19 THA, 3 TEA, 1 TAA and 1 TSA) during treatment with ETN. The incident rate of total joint replacement was determined by the Kaplan-Meier method. Statistical different was tested by Log-rank test. To identify risk factors for incidence of total joint replacement, impact of baseline clinical variables were analyzed by using Cox proportional hazards regression analysis.
Results Patients were predominantly female (83.9%), and had a mean age of 59 years, disease duration of 10.9 years and DAS28-ESR of 5.4 at initiation of ETN. MTX was concomitantly used with 70.4% of the patients. Mean time between initiation of ETN and total joint replacement was 1.5 years. The incident rate of total joint replacement for the patients with concomitant MTX was significantly lower than that for the patients without concomitant MTX (6.7 vs 12.3% at 5years, p=0.032, Figure1). Multivariate analysis identified no concomitant MTX use and age at initiation of ETN as the independent risk factors for incidence of total joint replacement (Table 1). Radiographic data was not available in the registry data though the existing joint damage at baseline would affect the need for total joint replacement.
Conclusions This study demonstrated that combination therapy with ETN plus MTX was superior to ETN alone in reducing the incidence of large joint replacement surgery.
Our data support the EULAR recommendation. ETN should be used preferentially in combination with MTX to inhibit progression of large joint destruction as well as hand and foot joint destruction.
van der Heijde D. Arthritis Rheum 2006; 54: 1063-74
Hideto Kameda. J Rheumatol 2011; 38: 1585-92
Wolfe F. Arthritis Rheum 1998; 41: 1072-82
Disclosure of Interest None declared
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