Conventional DMARD options for patients with a suboptimal response to methotrexate.

Methotrexate (MTX) is one of the disease modifying antirheumatic drugs (DMARD) commonly used to treat rheumatoid arthritis (RA). However, MTX therapy alone rarely results in remission and frequently does not even produce 50% improvement. Therefore, over the course of their disease, many patients will require additional therapy to manage their clinical symptoms. A number of treatment options have proven effective for such patients, most of which entail the continuation of MTX therapy and the addition of other DMARD. Although the combination of MTX and hydroxychloroquine (HCQ) is the one most commonly used in the US, many clinicians (particularly in Europe) prefer the combination of MTX and sulfasalazine. In addition, excellent data now exist for the triple combination of MTX, HCQ, and sulfasalazine in patients who have had a suboptimal response to MTX, as well as in those with early or well established disease. Other combinations, including MTX + cyclosporine or leflunomide, have also been helpful in some patients. Most recently, the tumor necrosis factor blockers, etanercept and infliximab, have successfully been used to treat a number of patients resistant to MTX. The combination of MTX with DMARD or biological agents with different mechanisms of action greatly expands the treatment options for patients with RA.