Biologic and Oral DMARD Monotherapy in RA
Biologic and Oral DMARD Monotherapy in RA
Patients without a contraindication for MTX who decline its use, and those considering discontinuation, may benefit from counselling and education. Patients can be encouraged to use MTX if the potential for progressive joint damage and loss of efficacy with discontinuation or non-compliance is explained.
Several approaches may improve MTX tolerability. Regular monitoring for signs of hepatic, renal or haematological AEs is advised. Dose adjustment or interruption with reinstatement at a lower dose may be considered if hepatotoxicity is evident.
Switching from oral to intramuscular or subcutaneous (SC) MTX may benefit patients with poor adherence or gastrointestinal AEs. A retrospective study of 191 patients in the UK who switched from oral to SC MTX (2003–2011) showed among 53 patients who switched because of intolerance, 40 (75.5%) subsequently tolerated parenteral therapy. Another RCT comparing oral and SC MTX found no difference in tolerability, though SC administration demonstrated better clinical efficacy at the same dosage. An alternative strategy for improving MTX tolerability is twice-weekly dosing, which increases the bioavailability of MTX above once-weekly dosing; a preliminary study, however, did not demonstrate an efficacy advantage over once-weekly dosing. Potential adjunctive therapies to mitigate AEs include folate supplementation, which reduces MTX-associated hepatic AEs, and antiemetics, which suppress MTX-induced nausea and vomiting.
Switching to another conventional DMARD may be an option in MTX-intolerant patients receiving combination therapy. Registry data and case series indicate rituximab plus leflunomide is a viable alternative to rituximab plus MTX, with potentially better tolerability. By contrast, a high incidence of AEs has been reported with infliximab plus leflunomide. Tocilizumab and abatacept, in combination with some non-MTX DMARDs, demonstrated good tolerability.
Several TNFi agents are effective as monotherapy, and biologic monotherapy is currently prescribed in patients who are, for one reason or another, not going to use MTX. However, the efficacy of these agents is generally enhanced by concurrent MTX administration.
Therapeutic Strategies in Patients Discontinuing or Not Initiating MTX
Patients without a contraindication for MTX who decline its use, and those considering discontinuation, may benefit from counselling and education. Patients can be encouraged to use MTX if the potential for progressive joint damage and loss of efficacy with discontinuation or non-compliance is explained.
Several approaches may improve MTX tolerability. Regular monitoring for signs of hepatic, renal or haematological AEs is advised. Dose adjustment or interruption with reinstatement at a lower dose may be considered if hepatotoxicity is evident.
Switching from oral to intramuscular or subcutaneous (SC) MTX may benefit patients with poor adherence or gastrointestinal AEs. A retrospective study of 191 patients in the UK who switched from oral to SC MTX (2003–2011) showed among 53 patients who switched because of intolerance, 40 (75.5%) subsequently tolerated parenteral therapy. Another RCT comparing oral and SC MTX found no difference in tolerability, though SC administration demonstrated better clinical efficacy at the same dosage. An alternative strategy for improving MTX tolerability is twice-weekly dosing, which increases the bioavailability of MTX above once-weekly dosing; a preliminary study, however, did not demonstrate an efficacy advantage over once-weekly dosing. Potential adjunctive therapies to mitigate AEs include folate supplementation, which reduces MTX-associated hepatic AEs, and antiemetics, which suppress MTX-induced nausea and vomiting.
Switching to another conventional DMARD may be an option in MTX-intolerant patients receiving combination therapy. Registry data and case series indicate rituximab plus leflunomide is a viable alternative to rituximab plus MTX, with potentially better tolerability. By contrast, a high incidence of AEs has been reported with infliximab plus leflunomide. Tocilizumab and abatacept, in combination with some non-MTX DMARDs, demonstrated good tolerability.
Several TNFi agents are effective as monotherapy, and biologic monotherapy is currently prescribed in patients who are, for one reason or another, not going to use MTX. However, the efficacy of these agents is generally enhanced by concurrent MTX administration.
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