MTX and Biologics in Real-life RA

I’ve just looked at twitter and found:

Here’s the corresponding link: http://ard.bmj.com/content/early/2013/09/17/annrheumdis-2013-203485.full.pdf+html

It leads you to an interesting article:

“Biologic and oral disease-modifying antirheumatic

drug monotherapy in rheumatoid arthritis

Paul Emery, Anthony Sebba, Tom W J Huizinga”

The authors tell us about “the perception that coadministration of MTX with all biologic agents or oral disease-modifying antirheumatic drugs is necessary for maximum efficacy.” In real-life we prescribe biologics as monotherapy in 1/3 of of patients. The authors talk about 58% of patients, who do not collect MTX prescriptions (analysis of healthcare claims data). I know of colleagues, who prescribe very low doses of MTX here in Germany to patients, who than discard MTX as they don’t tolerate it, but the prescription is needed not to work off-label, which might, at least here, induce recourse procedures by insurance companies. We recently discussed the problem of MTX adherence/compliance in a meeting of rheumatologists from the Aachen-Cologne-Düsseldorf area. The colleagues from Aachen insisted strongly on persuading patients, who complain about MTX side effects, to continue the drug. This would be in concordance with the findings of the authors, as they looked at “peer-reviewed literature and rheumatology medical congress abstracts to determine whether data support biologic monotherapy as a treatment option for patients with rheumatoid arthritis.” They came to the conclusion: “Our analysis suggests only for tocilizumab is there evidence that the efficacy of biologic monotherapy is comparable with combination therapy with MTX.”

Please read the whole article!

What now? I recall quite a lot of patients, who tell me, when they see the syringe of even the MTX package they’d like to vomit. Most other options are off-label. Prescribing low dose MTX and know that the patient won’t take it? Hope for not being sued for recourse on the off-label road? We’ll see how it works out in real-life. What I’ll do is stopping MTX in patients on tocilizumab. We can’t put all patients, who need monotherapy, on tocilizumab as the drug has its own issues.

Lots of questions rising from the article, but we already have some solutions. Legal solutions lack behind.