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There is already substantial evidence that monotherapy with Methotrexate is inferior to combination therapy using methotrexate, hydroxychloroquine and/or sulfasalazine with or without initial steroid therapy. It is therefore bad science to continue to start patients on methotrexate alone. Many of the trials of biologic agents have not been done against optimal "conventional" combination therapy, and while these often show a significant advantage over methotrexate alone the results shown here certainly confirm the need to abandon monotherapy as a starting point, and begin with combination therapy - perhaps even as a precondition before allowing biologic therapy.
The cost savings may be substantial; if even half of a district hospital's rheumatoid arthritis population could be controlled on conventional therapy started early and hard, then we could be seeing a drug bill reduction of perhaps £1.5m annually. Per hospital.
Furthermore all future trials of new biologic agents should be against combination therapy regimes, or the apparent superiority of biologic agents will continue to be overstated.