MTX +dual DMARD compared to MTX + etarnecept

My original comments published in http://www.nejm.org/doi/full/10.1056/NEJMoa1303006#t=comments


The study showed a very promising results for triple therapy (methotrexate plus sulphasalazine plus hydroxychloroquine) with no difference significantly compared to methotrexate and etarnecept. The study potentially will give impact to management of rheumatoid arthritis as conventional triple therapy is much cheaper than methotrexate and etarnecept . Firstly combination conventional triple therapy potentially cheaper than methotrexate plus biologics. Secondly the initiating of triple therapy with relatively higher dose as starter therapy compared with normal treatment of DMARD with tapering dose according to response to therapy. NICE guideline only suggest initiate methotrexate with at least one other DMARD. I find this study commencing the aggressive therapy with the results of severe adverse events been observed ( 1mortality in biologics arm and severe infection in both arm). There is not mentioned folate in addition of methotrexate to prevent side effect of methotrexate . I personally suggest and conduct a routine chest radiograph before initiate biologics as pulmonary tuberculosis is relatively common in Malaysia.