Combination therapy in rheumatoid arthritis

Abstract

The definition of combination therapy is difficult, as the prescribing of several drugs concurrently is standard practice in rheumatoid arthritis (RA). In addition to disease-modifying anti-rheumatic drugs (DMARDs), non-steroidal anti-inflammatory drugs (NSAIDs) and systemic and local corticosteroids are almost invariably given. However, the standard definition of combination therapy is of two DMARDs being given simultaneously, and it is this definition that will be used here. Whilst 10 years ago combination therapy was a rarity, now it is used by the majority of rheumatologists [32]. In light of increasing evidence that persistent disease activity is associated with a worse outcome in terms of end organ destruction and disability [54], the rationale for combination therapy is multiple. First, more intensive therapy has shown to be more effective in patients with RA not in remission on monotherapy. Second, more therapy has not been shown to be more toxic. Thus, increasing the doses of combination therapy has become standard, although there is a great debate about whether this should be used as a blanket approach in early disease. A step-up approach (adding in successive therapies following inadequate response) is used in most cases of RA, but there is some evidence that combination therapy in early disease can have a beneficial effect without increased toxicity [5]. Finally, recent advances in assessment of disease activity using imaging techniques (magnetic resonance imaging and high-resolution ultrasonography) allow detection of subclinical synovitis and will increase expectations from new therapies and combinations.