Triple Therapy vs Biologic/MTX: the debate rages

By Dr Irwin Lim, Rheumatologist

I've been following the American College of Rheumatology Meeting in San Diego on twitter.

There's been a fair bit of chatter regarding the relative merits of using Triple Therapy (Methotrexate/Sulphasalazine/Hydroxychloroquine) for Rheumatoid Arthritis compared to biologic therapy/Methotrexate therapy after the failure of Methotrexate as monotherapy.

I'd previously written about the thought-provoking O'Dell paper that has reignited this debate. Read it here.

There's no denying that biologic therapy is really very expensive. All developed countries have budgets in deficit and the money printing will have to stop sometime. Health costs are soaring and we as rheumatologists are definitely adding to the bill.

This debate counts.

And yet, I must admit I haven't changed my practice yet.

I sit here trying to justify why this is the case to myself and the points I've come up with:

• Pill Load: With triple therapy, 2 or more tablets Methotrexate weekly, at least 1-7 tablets of folic acid weekly, 4 tablets of sulphasalazine daily, 2 tablets of hydroxychloroquine daily, add in some Prednisone early in the treatment cycle, possibly calcium and vitamin D supplementation, possibly fish oil. A patient will need at least 45-50 tablets a week.
• With the 1st point, compliance is likely to be poor. Sorry, but I find it hard to believe most of my patients will adhere to taking all these.
• Confusion. Mine. With different medication started together, it's harder to work out if and when a side effect occurs, which therapy to blame? To enable me to stop or modify it.
• The baseline characteristics of the patients in the trial reported seem different from mine. The patients had late disease, at a mean of 5 years post-diagnosis. They seem older than my usual group with an age mean around 57 years.
• The patients had been on Methotrexate as monotherapy for at least 12 weeks and were doing quite badly with a high mean DAS28 of 5.8, mean swollen joint score of 11 and mean tender joint score of 13. Our treat-to-target mantra would usually have meant some combination therapy would already have been started unless there were good reasons not to.

Now, I'm likely just justifying what I do.

I still try to treat aggressively and I still treat-to-target, seeing my Rheumatoid Arthritis patients regularly while aiming for remission or a state as close as possible to this. I use Methotrexate then add in Hydroxychloroquine and/or Salazopyrin EN early if our targets are not being met. I just don't tend to start the whole lot as described.

And yet, I do understand the financial imperative to use cheaper drugs if possible. After all, it's your tax dollars and it's my tax dollars.

If I had to pay and if you had to pay (rather than our funding bodies subsidising the treatments greatly), would we do something different?

The answer I think is (maybe) yes. We would use this triple therapy regime earlier. We would justify it better. Rheumatologists would cajole more.

And maybe, I won't need this introspective yet on-line discussion. My funding body, the government, may eventually take it out of my hands and mandate that we use triple therapy as described as part of the process to gain access to biologic medication.

These are my thoughts. What are yours?