Abstract
How effective is methotrexate (MTX) in psoriatic arthritis (PsA)? Should we use MTX in combination with biologic therapy in PsA? Does MTX increase therapeutic benefit when used in combination with biologics, either because of its own immunomodulatory effect or its ability to decrease immunogenicity to biologics? Or does MTX not provide additional benefit over and above the biologic agent? Instead, does it contribute only problems from a tolerability and safety perspective? Despite the fact that MTX is the most commonly used immunomodulatory drug in PsA, these questions still have not been satisfactorily answered. A variety of studies sheds light on these questions, but uncertainty remains. In this issue of The Journal , Behrens, et al study a large registry cohort in Germany to attempt to address a corollary question1. Knowing that MTX is not effective in treating the spinal symptoms of ankylosing spondylitis2, they ask the following question: In a cohort of patients with PsA, about half treated with adalimumab (ADA) monotherapy and half with concomitant MTX, if PsA subjects with spondylitis symptoms are analyzed separately from those with peripheral inflammatory musculoskeletal symptoms only, is there any difference in response to 2 years of treatment based on MTX background? There have been few placebo-controlled trials to establish the efficacy of MTX in PsA using the low-dose MTX regimen used for the treatment of rheumatoid arthritis (RA) and psoriasis. Neither Willkens, et al nor Kingsley, et al were able to demonstrate benefit of MTX over placebo as assessed by arthritis measures used at the times of those trials, although patient global assessment and some skin measures showed modest improvement3,4,5. Arguably, these were not fair trials in that the first trial studied few patients and included a low-dose arm (7.5 mg as … Address correspondence to Dr. P.J. Mease, Seattle Rheumatology Associates, 601 Broadway, Suite 600, Seattle, Washington 98122, USA. E-mail: pmease{at}philipmease.com
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