RA: MTX monotherapy with glucocorticoid bridging is best induction strategy

  • Rheumatology

  • von Miriam Davis, PhD
  • Clinical Essentials
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Takeaway

  • In early rheumatoid arthritis (RA), the 2-year results of the Care in Early RA (CareRA) randomized controlled trial (RCT) find that methotrexate (MTX) monotherapy with glucocorticoid bridging (stepped-down prednisone; the COBRA-Slim group) has similar efficacy to MTX+another conventional synthetic disease-modifying antirheumatic drug (csDMARD), but fewer adverse events (AEs).

Why this matters

  • COBRA-Slim is the best early treatment strategy for patients with radiographic damage.

Study design

  • Multicenter RCT (n=400) in Belgium of high-risk (evidence of radiographic damage) and low-risk patients.
  • High-risk patients were randomly assigned to 1 of 3 groups, each with 15 mg MTX weekly+prednisone step-down: COBRA-Slim (MTX+prednisone step-down starting at 30 mg), COBRA Classic (MTX+2 g daily sulfasalazine+prednisone step-down starting at 60 mg), or COBRA-Avant-Garde (MTX+10 mg daily leflunomide+prednisone step-down starting at 30 mg).
  • Low-risk patients were randomly assigned to 1 of 2 groups: COBRA-Slim or Tight Step Up (MTX+no prednisone step-down).
  • Efficacy was assessed by several methods, including the 28 joint Disease Activity Scale using C-related peptide (DAS28-CRP
  • Funding: Flemish Governmental Agency for Innovation by Science and Technology.

Key results

  • At 2 years, no differences in >12 efficacy measures including DAS28-CRP
  • COBRA-Slim had fewer therapy-related AEs vs COBRA-Classic (P=.02) or COBRA-Avant-Garde (P=.005).
  • No differences in AEs in low-risk groups.

Limitations

  • Small sample sizes.