Efficacy of triple association methotrexate, sulfasalazine and hydroxychloroquine in early treatment of rheumatoid arthritis with insufficient response to methotrexate: Meta-analysis of randomized controlled trials

ObjectivesTo evaluate the efficacy of the triple synthetic Disease Modifying Anti-Rheumatic Drugs (sDMARD) combination methotrexate, sulfasalazine and hydroxychloroquine versus a biologic DMARD (bDMARD) in the treatment of early rheumatoid arthritis.MethodsA systematic literature search was performed using the PubMed and Cochrane databases, and abstracts presented at rheumatology scientific meetings until December 2013. Randomized controlled trials comparing the efficacy and the safety of biologic DMARD with the triple combination were included. Outcome measures were Van der Heijde modified Sharp score (SHS), remission rate, ACR criteria response, adverse events.ResultsA total of 1225 abstracts were screened. We extracted data from 5 trials including patients (515 in the triple combination group and 710 in the bDMARD group). We showed higher ACR70 response (OR = 1.79, 95% CI [1.17, 2.72]) in patients treated with bDMARDs, whereas radiological progression was not different from patient with triple combination (OR = 1.10, 95% CI [-0.04, 0.28]). At year 2, ACR70 response and remission rate, the results were similar in both groups with respectively OR = 1.44 (95% CI [0.86, 2.43]) and SMD = 0.45 (95% CI [0.17, 0.72]). The proportion of serious adverse events was similar in both groups OR = 1.02 (95% CI [0.68, 1.52], P = 0.92, I2 = 0%). Gastro-intestinal adverse events were higher in the triple combination group (OR = 1.75, 95% CI [0.73, 4.21], P = 0.21, I2 = 75%). Infectious adverse events were more frequent in the bDMARD group (OR = 0.50, 95% CI [0.35, 0.70], P < 0.0001, I2 = 36%).ConclusionBiological treatment seems to be more efficient than triple combination in terms of radiological progression in RA with inadequate response to methotrexate.