How to Use Etanercept for RA

January 24, 2013

A randomized trial shows that adding etanercept to methotrexate achieves low disease activity in a large majority of patients with moderately active rheumatoid arthritis

Rheumatoid Arthritis

 

Maintenance, reduction, or withdrawal of etanercept after treatment with etanercept and methotrexate in patients with moderate rheumatoid arthritis (PRESERVE): a randomised controlled trialThe Lancet Available online Jan 17, 2013, Full text $31.50

Adding etanercept to methotrexate is effective for moderately active rheumatoid arthritis (RA), but etanercept must be continued at a low dose to maintain the improvement. That's the result of a randomized, controlled trial designed to address questions left unanswered in earlier studies:

(1)  whether biological agents, in this case etanercept, could be tapered (yes) or discontinued entirely (no), and

(2) how to treat patients with moderately active RA (disease activity score in 28 joints >3.2 and ≤5.1), an understudied population.

In a two-step design, patients with inadequate control on methotrexate were given an added 50 mg weekly of etanercept for 36 weeks. About 72% (604) of those patients had a response. The 604 patients were then randomized to 50 mg weekly, 25 mg weekly, or placebo for another 52 weeks. About 80% of patients on either dose of entanercept reached low-disease activity at 88 weeks, compared to about 40% on placebo. Rheumatoid arthritis: still a chronic diseaseThe Lancet, Available online Jan 17, 2013, Full text $31.50

In a commentary, Pierre Miossec draws three important conclusions from the PRESERVE study: First, low disease activity in patients with rheumatoid arthritis can be maintained with a combination of methotrexate and etanercept. Second, dosage can be reduced. Third, there was no significant difference in infections between the two dosage groups and placebo. However, the drug is expensive and they may have to stay on this treatment for a long time. Still, the combination can prevent joint destruction. The results could be improved with early treatment based on early diagnosis from biomarkers, which appear years before clinical manifestations. Early and late RA are diseases with different pathways.