Rheumatoid Arthritis: Are Two Drugs Better than One?

Dr Janet E Pope Division of Rheumatology, Department of Medicine The University of Western Ontario, St Joseph's Health Centre 268 Grosvenor Street, London, ON, Canada N6A 4V2MedicalResearch.com Interview with:
Dr. Janet E Pope
Division of Rheumatology, Department of Medicine
The University of Western Ontario, St Joseph’s Health Centre
268 Grosvenor Street, London, ON, Canada N6A 4V2


MedicalResearch.com: What are the main findings of the study?

 Dr. Pope: We performed a RCT of patients who were stable for 6 months of etanercept added to methotrexate (inadequate responders to Mtx) who were randomized to stopping Mtx or continuing Mtx to determine if in the next 6 months (and later as the trial continues) the response rate would be the same if Mtx was discontinued. Overall, Mtx + etanercept was not statistically equivalent to etanercept alone (ie non-inferiority did not occur); implying 6 months after stopping Mtx, the etanercept patients on monotherapy performed slightly less well than those on combination therapy.

In a pre-specified subset analysis, both patients who started in lower DAS28; and/or were in a low DAS28 at 6 months seemed to do equally well if Mtx was stopped or continued, but if not in a low DAS28 at 6 months, stopping Mtx on average slightly worsened the DAS28.

MedicalResearch.com: Were any of the findings unexpected?

Dr. Pope: Yes and no. Most studies have shown that two drugs are better than one in RA. This seems to be the case in the CAMEO trial, but if in a low disease state, this likely can be maintained for at least another 6 months after Mtx is discontinued. We are looking at a longer durability of response and drop out rate for those in each treatment group to see if in the long term (as may be found in some registries), Mtx is better for less drop out over time.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Pope: If in a low disease state in RA with Mtx and etanercept, perhaps Mtx can be stopped but if not in remission or a low disease state Mtx should not be stopped. We can’t answer about lowering Mtx or lowering etanercept as that was not part of this study.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Pope: It would be interesting to answer the above questions (dose reduction of one drug or the other) and we will look at retention in the study (both drop outs and maintaining response) in the two groups for another 12 months and we have the pharmacogenomics on the patients to determine if there are certain genes that predispose to more or less retention for both treatment arms.


The Canadian Methotrexate and Etanercept Outcome Study: a randomised trial of discontinuing versus continuing methotrexate after 6 months of etanercept and methotrexate therapy in rheumatoid arthritis Janet E Pope, Boulos Haraoui, J Carter Thorne, Andrew Vieira, Melanie Poulin-Costello, Edward C Keystone

Ann Rheum Dis annrheumdis-2013-203684Published Online First: 26 August 2013 doi:10.1136/annrheumdis-2013-203684