Improved Rheumatoid Arthritis Remission With Combined Therapy

For
patients with active, early stage, moderate-to-severe rheumatoid
arthritis, a combination treatment with methotrexate and etanercept can
improve remission and radiographic non-progression rates within one
year in comparison with just methotrexate. Additionally, more patients
are also able to remain employed. These conclusions are published in an
article released early Online on July 16, 2008 in The Lancet.




Rheumatoid
arthritis is an autoimmune disorder in which the immune system attacks
the joints, causing arthritic inflammation and damage. It can also
extend to other parts of the body. Early in therapy, successful
treatments induce remission, usually by reducing or eliminating
inflammation. If progression of the disease is caught at an early
stage, when it can be most destructive, serious joint damage could be
prevented.



To investigate potential treatment methods for
rheumatoid arthritis, Paul Emery, Professor of Rheumatology, University
of Leeds, UK and Leeds Teaching Hospitals Trust, UK, performed the
COMET study, a randomized trial comparing combination treatment with
individual treatment. A total 542 patients with early
moderate-to-severe RA for 3-24 months who had not been treated with
methotrexate were randomle assigned to one of the following groups:
only methotrexate (268 patients), or methotrexate and etanercept (274
patients). Methotrexate was administered with a starting dose of 7.5 mg
per week to a maximum 20 mg per week at the end of 8 weeks. The
entanercept was administered at 50 mg per week. A disease activity
score (DAS28) was evaluated with a radiographic non-progression measure
(Sharp score) after one year.



It was found that 50% of patients who were given the combined treatment
achieved remission, while 94% of this group had a good to moderate
response. In comparison, the methotrexate only group had a 28%
remission rate, making the combined group members almost twice as
likely to achieve remission. In a comparison of radiographic
non-progression, 80% of combined treatment patients achieved the mark,
while only 58% achieved this in the only methotrexate group. The
serious adverse events were similar in the two groups.



The authors summarize their findings while making a statement about the
increased functionality of patients who are able to bring rheumatoid
arthritis into remission early. "The COMET trial showed that patients
who received combination therapy have a nearly three-fold reduction in
work stoppage compared with those who took high- dose methotrexate
alone. The ability to remain a productive member of the workforce has
implications for patients, employers, and society as a whole. The
effect of RA is especially significant for women aged 55-64 years,
because they have a high incidence of stopping work early...nearly a
quarter of patients who were in employment at baseline in the COMET
trial had stopped working at least once by the end of 1 year compared
with about a tenth in the combination group."



According to the authors, this is data is evidence for the combined
treatment. "The results of the COMET trial suggest that remission is an
achievable goal in patients with early severe RA within the first year
of therapy with etanercept plus methotrexate....The positive clinical
outcomes in the combination treatment group also seem to determine the
ability of patients to remain in employment. Furthermore, these
outcomes appear to be achieved without exposing patients to significant
additional risk."



Dr Joel Kremer, Center for Rheumatology, Albany Medical College,
Albany, NY, USA, contributed an accompanying comment stating that there
must be a specific system for ensuring that this kind of therapy is
cost effective and efficiently implemented. "Experts in health
economics can apply rigorous formulae to quality of life and
disability, while factoring in cost of drugs and their toxic effects,
to establish whether the promising data in these investigations are
sustained, and whether the new biological agents are cost effective."
He says.



Comparison
of methotrexate monotherapy with a combination of methotrexate and
etanercept in active, early, moderate to severe rheumatoid arthritis
(COMET): a randomised, double-blind, parallel treatment trial

Paul
Emery, Ferdinand C Breedveld, Stephen Hall, Patrick Durez, David J
Chang, Deborah Robertson, Amitabh Singh, Ronald D Pedersen, Andrew S
Koenig, Bruce Freundlich

Published Online The Lancet July 16, 2008

DOI:10.1016/S0140- 6736(08)61000-4

Click Here For Journal



COMET's path, and the new biologicals in rheumatoid arthritis

Joel M Kremer

Published Online The Lancet July 16, 2008

DOI:10.1016/S0140- 6736(08)61001-6

Click Here For Journal



Written by Anna Sophia McKenney