Are DMARDs effective for rheumatologic diseases besides rheumatoid arthritis?

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Clinical Inquiries

Are DMARDs effective for rheumatologic diseases besides rheumatoid arthritis?

J Fam Pract. 2007 November;56(11):933-937

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References

1. Bongartz T, sutton AJ, Sweeting MJ, et al. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA 2006;295:2275-2285.

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7. Chen J, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database Syst Rev 2006;(4):CD004524.-

8. Heijde D, Dijkmans B, Geusens P, et al. efficacy and safety of infliximab in patients with ankylosing spondylitis. Arthritis Rheum 2005;52:582-591.

9. Calin A, Dijkmans BA, Emery P, et al. Outcomes of a multicentre randomized clinical trial of etanercept to treat ankylosing spondylitis. Ann Rheum Dis 2004;63:1594-1600.

10. Grout K, Rasmussen N, Bacon P, et al. randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheum 2005;52:2461-2469.

11. Jover JA, Hernandez-Garcia C, Morado IC, et al. Combined treatment of giant-cell arteritis with methotrexate and prednisone. a randomized, double blinded, placebo-controlled trial. Ann Intern Med 2001;134:106-114.

12. Hoffman GS, Cid MC, Hellmann DB, et al. A multicenter, randomized, double-blind, placebo-controlled trial of adjuvant methotrexate treatment for giant cell arteritis. Arthritis Rheum 2002;46:1309-1318.

13. Sankar V, Brennan MT, Kok MR, et al. etanercept in sjögren’s syndrome: a twelve-week randomized, double-blind, placebo-controlled pilot clinical trial. Arthritis Rheum 2004;50:2240-2245.

14. Wegener’s Granulomatosis etanercept Trial (WGeT) research Group. etanercept plus standard therapy for Wegener’s granulomatosis. N Engl J Med 2005;352:351-361.

15. Salvarani C, Olivieri I, Pipitone N, et al. recommendations of the Italian society for rheumatology for the use of biologic (TNF-alpha blocking) agents in the treatment of psoriatic arthritis. Clin Exp Rheumatol 2006;24:70-78.

16. Zochling J, van der Heijde D, Dougados, et al. Current evidence for the management of ankylosing spondylitis: a systematic literature review for the AsAs/eulAr management recommendations in ankylosing spondylitis. Ann Rheum Dis 2006;65:442-452.

For other rheumatic diseases, studies are mixed

Due to cyclosporine’s toxicity, less toxic DMARDs are being evaluated to replace it for treatment of other rheumatic diseases. A recent randomized controlled trial of 100 patients with antineutrophil cytoplasmic antibody–associated systemic vasculitis showed methotrexate may be able to replace cyclosporine for both induction of remission (methotrexate=89.8% vs cyclosporine=93.5%; P=.041) and maintenance of remission (69.5% vs 46.5% at 18 months; P=.023).¹⁰

Initial trials on other rheumatic diseases have been small and have had varied results. There are mixed studies on the effectiveness of adding methotrexate to corticosteroids for giant cell arteritis.^11,12

There has been no evidence of efficacy for the new TNF antagonists in either a small study on Sjögren’s syndrome (n=14)¹³ or a larger study on Wegener’s granulomatosis (n=180).¹⁴

The studies for use of DMARDs in lupus or scleroderma are of limited quality.

Recommendations from others

The Italian Society for Rheumatology consensus guidelines recommends TNF antagonists be considered in active psoriatic arthritis resistant to (a) NSAIDs, (b) at least 2 local steroid injections, and (c) at least 2 conventional DMARDs for patients with peripheral arthritis or enthesitis. They also recommend TNF antagonists be considered for psoriatic spondylitis resistant to NSAIDs.¹⁵

FAST TRACK

For Sjögren’s syndrome, lupus, giant cell arteritis, and scleroderma, study results are mixed or limited

The Assessment in Ankylosing Spondylitis (ASAS) International Working Group and the European League Against Rheumatism (EULAR) recommendations for the treatment of ankylosing spondylitis, based on a systematic review of the literature and expert opinion, indicate that:

There is good evidence for using NSAIDs and COX-2 inhibitors for symptomatic treatment.
Conventional DMARDs are not well supported.
TNF antagonists show a large benefit in both pain and function.

The ASAS/EULAR recommendation indicate that there is no evidence that any of these treatments actually modify the disease progression.¹⁶

Acknowledgments

The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force medical service or the US Air Force at large.

Evidence-based answers from the Family Physicians Inquiries Network