SANDESTIN, FLA. – A conservative approach to early rheumatoid arthritis treatment has carried the day in the practice of Gerd R. Burmester, MD.
In a talk at the annual Congress of Clinical Rheumatology, Dr. Burmester said that, although there is room to argue for a more aggressive approach, with more intense treatment early, a less aggressive philosophy has worked well in his clinic.
Dr. Gerd R. Burmester
Dr. Burmester, director of rheumatology and clinical immunology at Charite-University in Berlin and a past president of the European League Against Rheumatism (EULAR), said he drew inspiration from the results of the 2015 study CARE-RA, in which patients were treated with initial therapy of methotrexate plus sulfasalazine and a fairly high dose of 60 mg of prednisolone; methotrexate plus leflunomide plus 30 mg of prednisolone; or just methotrexate plus 30 mg of prednisolone that is quickly tapered down (Ann Rheum Dis. 2015 Jan;74[1]:27-34).
“Everyone would say, ‘Okay, this is quite easy – the more intensive drug regimen should give you better results,’ ” Dr. Burmester said. “But if you look at the data, there’s no difference.” And after just 8 weeks, the patients’ corticosteroid dose was down to 5 mg.
This, he said, “has changed my daily typical practice, quite a bit.”
“I start with, usually, 15 mg of methotrexate subcutaneously,” because of better efficacy and less liver toxicity than oral administration, he said, or an oral dose if a patient resists the subcutaneous administration or there is another reason to avoid it. “And I add 30 mg of prednisone and taper it down – 30, 20, 12.5 mg, and then down to 5 and eventually discontinued altogether.”
“This is an interesting scheme,” he said. “And this is exactly what I do with my patients.”