The 1 percent of the population who...

The 1 percent of the population who are affected on rheumatoid arthritis face reduced life expectancy, significant pain, and functional los The goals of treatment are to obstruct joint damage, suppress disease activity, and improve quality of life. Because tumor necrosis factor (TNF) plays a crucial part in the pathogenesis of rheumatoid arthritis, TNF-blocking agents like as etanercept have been used to form disease activity and slow joint destruction. Klareskog and colleagues studied the combination of etanercept and methotrexate in patients in whom other disease-modifying antirheumatic remedy treatments had failed.

They studied nearly 700 adult patients who had active rheumatoid arthritis (American guild of Rheumatology [ACR] class I to class III) and who had an unsatisfactory reply to at least one disease-modifying unsalable article other than methotrexate. Patients were exclud from the inquiry if they had used methotrexate within six month or had experienced a bad reaction to this mix with drugs Other reasons for exclusion were previous use of TNF antagonists, newly come use of disease-modifying drugs or steroids, and any significant comorbid conditions.

The patients were assigned randomly to common of three treatment groups, all of whom received medications and injections that were identical in appearance. Initially, the 228 patients assigned to methotrexate alone received an oral dosage of 75 mg by week that increased to 20 mg by week over eight weeks if indicated from joint symptoms. The 223 patients assigned to etanercept alone received a dosage of 25 mg subcutaneously twice weekly. The remaining 231 patients received subcutaneous etanercept and oral methotrexate. All patients received a folic acid add to twice weekly. Patients were monitored at 24 and 52 weeks for changes in the radiographic appearance of joints, ACR score of disease activity, and disability as measured from the health assessment questionnaire. Patients were assessed clinically and questioned about side issues during the study.

During the first year, 160 patients withdrew from the research mainly because of side powers Only six patients in the combination cluster withdrew because of lack of efficacy, compared with 21 patients in the methotrexate clump and 16 patients in the etanercept arrange Radiographic scores did not differ significantly among the clusters at baseline, but the combination treatment was long more effective in retarding joint damage than methotrexate or etanercept alone.

At united year, 80 percent of the combination treatment assemblage showed no radiologic progression, compared with 68 percent of the etanercept cluster and 57 percent of the methotrexate clump Patients receiving combination therapy were significantly more likely to achieve gains in ARC scores, measures of disease activity, and quality-of-life assessments than either of the single-treatment arranges At one year, 35 percent of the combination dispose had achieved remission, compared with 16 percent of the etanercept clump and 13 percent of the methotrexate clump Adverse events were common, being reported on more than 80 percent of patients in each arrange The types and prevalence of adverse ends were comparable across the three treatment groups

The authors judge that the combination of etanercept and methotrexate is significantly more effective than either agent alone in retarding the disease proces achieving remission, and improving function and quality of life. They point public that the negative progression scores onward the radiographic assessments confirm the controversial report of an earlier research indicating that repair of rheumatologic joint damage is possible.

EDITOR'S NOTE: After a prolonged period of little progress, fresh treatments offer real hope to patients with rheumatic diseases. This cogitation challenges family physicians on many evens The prospect of not just "disease-modifying" yet "disease-reversing" therapy is exciting. Family physicians must remain up to date, preserve our patients informed of unfoldings and ensure that they do not persist with outdated or dangerous therapies. reciprocally the new treatments have multiple side imports significant costs, and unknown long-term results Patients, families, and third-party payors face difficult decisions in balancing the pro and learn by hearts of the new treatments. Nevertheless, the rise high in research on these leave out of viewed conditions is welcome. Can we confidence that the next generation of physicians will not descry patients with the severe joint destruction and damage to other schemes that are now common in older patients with rheumatoid arthritis?--A.D.W.

ANNE D WALLING, MD

Klareskog L et al. Therapeutic meaning of the combination of etanercept and methotrexate compared with each treatment alone in patients with rheumatoid arthritis: double-blind randomised controll trial. Lancet February 28 2004;363:675-81

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