According to a Cochrane network systematic review and network meta-analysis of 158 trials with more than 37000 patients with rheumatoid arthritis, “Triple therapy” (methotrexate + sulfasalazine + hydroxychloroquine) was superior to oral methotrexate for ACR50 response, in both methotrexate naive and methotrexate inadequate response populations.
A statistically significant benefit for other conventional synthetic DMARD combinations compared with oral methotrexate was also observed, but only after an inadequate response to methotrexate, and the magnitude of effect or quality of evidence was graded lower than for triple therapy.
Triple therapy costs 10-20 times less than biologic therapy, but is not currently recommended strongly by international guidelines. These results suggest that triple therapy should be tried as a low cost, effective treatment option either as initial treatment or as a step-up treatment in patients who show inadequate response to methotrexate alone.
The study is published online April 21 in The BMJ.