Thérapeutiques ciblées dans la polyarthrite rhumatoïde : en association à des traitements de fond conventionnels ou en monothérapie ?

Recent expansion of available or soon available targeted therapies for treatment of rheumatoid arthritis (RA) enhance the possibilities of therapeutic strategies in this disease. Current guidelines for management of RA recommend an “add-on” strategy starting with a conventional synthetic disease modifying antirheumatic drug (csDMARD) if possible methotrexate (MTX) and, if response to MTX is insufficient, adding a targeted therapy. Nonetheless, a third of patients for whom a biologic DMARD is prescribed take it in absence of concurrent csDMARD therapy. This may be explained by poor adherence to MTX due to minor intolerance leading patients or rheumatologists to stop treatment. Indeed, contraindications or severe side effects of MTX are very rare. Thus, it is important to know advantages and disavantages of using targeted therapies in monotherapy by comparison with the combination with a csDMARD. In this review, after reviewing the different situations for which targeted therapies could be prescribed in monotherapy, we will discuss the different elements to consider when a targeted therapy has to be prescribed in monotherapy. Thus, evidence based data on efficacy, tolerance, immunogenicity, medication adherence and cost will be succesively provided.