http://ard.bmj.com/content/early/2015/03/20/annrheumdis-2014-206758.full
Conventional DMARDs in axial spondyloarthritis: wishful––rather than rational thinking!Robert B M Landewé1,2
+ Author Affiliations
1Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
2Atrium Medical Center, Heerlen, The Netherlands
Correspondence to
Robert B M Landewé, Amsterdam Rheumatology and Immunology Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands; landewe@rlandewe.nl
Received 3 March 2015
Accepted 8 March 2015
Published Online First 20 March 2015
Conventional synthetic DMARD (csDMARD) therapy in patients with axial spondyloarthritis (SpA) is a matter of continuous debate. Part of this discussion is a dispute about methotrexate (MTX) comedication in patients with axial SpA treated with tumour necrosis factor inhibitors biologicals (TNFi). The dispute seems to be based on perceptions rather than scientific evidence and may have been fuelled by one of the European League Against Rheumatism task force on the management of rheumatoid arthritis (RA) recommendations. This recommendation states that in RA, TNFi-biologicals should be used in combination with MTX,1 which finds its justification in the results of multiple randomised clinical trials and careful posthoc analyses thereof.
(more...)(-----------)
"Taken together, Lie's study is an example of an observational study in which residual confounding seems a far too likely explanation for the association between TNFi-retention and csDMARD comedication to justify implementation in clinical practice. However, absence of evidence for a particular hypothesis is not the same as evidence for the absence of such a hypothesis! The best experiment to test the hypothesis that csDMARDs in axial SpA improve TNFi-retention is the well-powered RCT that randomises patients with axial SpA to either monotherapy with a biological or to combination therapy of a biological plus a csDMARD, follow them blindly for some time and compare clinical efficacy, safety and drug-retention in both arms. Such a trial is feasible, but costly, hard to fund and unfortunately not in the interest of pharmaceutical industries. This may explain why this trial likely will not be performed in near future. That is truly a pity, since for the benefit of our patients and the affordability of our healthcare systems we urgently need unequivocal answers to simple but extremely relevant clinical questions."
Footnotes
Competing interests The author is the current president of ASAS.
Full article available - free edition
