LETTER

Why is Methotrexate the First Selection inDisease-Modifying Antirheumatic DrugTherapy? Comment on the Articleby Wolfe et al

To the Editor:

I read with interest the findings of Wolfe et al (1) aboutratings of United States rheumatologists concerning dis-ease-modifying antirheumatic drug (DMARD) therapies.Recently, we performed a study to allow a better insightinto the current therapeutic approach to treat early rheu-matoid arthritis (RA) in Colombia (2).

In my country, there is a population of 35 million peopleand about 90 rheumatologists board certified by the Co-lombian Rheumatology Association. At a national meet-ing, 41 rheumatologists (45.5%) answered a survey regard-ing the current approach to treatment of RA. Theycompleted an anonymous questionnaire (single- and mul-tiple-choice questions with one or several answers) thatcontained 23 questions about treatment of RA andearly RA.

The DMARDs that they currently report using most withRA patients are methotrexate (MTX) (90% of rheumatolo-gists), chloroquine (CLQ) (51%), hydroxychloroquine(HCLQ) (24%), and sulfazalazine (SSZ) (15%). In a newlydiagnosed RA patient, Colombian rheumatologists an-swered that the more commonly prescribed (first choice)DMARDs are MTX (29%) or CLQ (29%), HCLQ (27%),parenteral gold (9%), and SSZ (5%). They start DMARDswhen patients fulfill the American College of Rheumatol-ogy (ACR) criteria for RA, but also in the absence of ero-sions (62% of the rheumatologists), or less frequentlywhen they suspect RA, even if the ACR criteria for RA arenot fulfilled (18%). Seventy percent of our rheumatologistsreport prescribing corticosteroids regularly, with 75% ad-ministering doses of prednisone below 10 mg and 60%reporting that this dosage be maintained as short a periodof time as possible. Sixty-four percent of rheumatologistsstart corticosteroids the first time as bridging therapy untilDMARDs are effective.

These results show that Colombian rheumatologists fa-vor early therapy in RA with DMARDs such as MTX, CLQ,or HCLQ. Overall, MTX is the most currently usedDMARD in Colombia. As in the US, MTX is actually thetop-rated DMARD. This finding could reflect currentchanges in RA therapy (3), but there may also be other

factors that affect rheumatologists’ prescriptions, such asdoctors’ and patients’ perceptions about DMARDs or com-pliance with use of the drugs (4). Finally, the cost ofmedicine has a great influence in the choice of drugs inLatin American countries, so in Colombia we tend to usemore MTX or CLQ than HCQL, intramuscular gold, orD-penicillamine.

MTX in Colombia, as in other places of the world, ischeap, is easy to use once a week, has a faster initialanti-inflammatory response compared with otherDMARDs, is a newer drug or treatment in comparison withgold or SSZ, and has the lowest drop-out rate of currentDMARDs (4,5). These could be some of the reasons whythe results of the Wolfe et al study are in agreement withobservational data, but differ substantially from results ofrandomized clinical trials (RCTs). It seems that it could bejust a matter of personal choices, patient compliance, and“added value” of drugs such as MTX, even if we know thatour clinical experience sometimes disagrees with RCTdata.

Carlo V. Caballero-Uribe, MD, FACR

Centro de Artritis y OsteoporosisBarranquilla, Colombia

1. Wolfe F, Albert DA, Pincus T. A survey of UnitedStates rheumatologists concerning effectiveness of dis-ease-modifying antirheumatic drugs and prednisonein the treatment of rheumatoid arthritis. Arthritis CareRes 1998;11:375–81.

2. Caballero-Uribe CV, Ramirez LA, Restrepo JF. Trata-miento de la artritis reumatoidea en Colombia. ActaMed Colomb 1998;23:260–86.

3. Emery P. Therapeutic approaches for early rheumatoidarthritis. How early? How aggressive? Br J Rheumatol1995;34 Suppl 2:87–90.

4. Sturrock R. Should methotrexate really be used as asecond-line drug in the management of rheumatoidarthritis? In: Isenberg D, Tucker LB, editors. Contro-versies in rheumatology. London: Martin Dunitz;1997. p. 39–46.

5. Cronstein BN, Naime D, Ostad E. The antiinflamma-tory mechanism of methotrexate: increased adenosinerelease at inflamed sites diminishes leukocyte accu-mulation in an in vivo model of inflammation. J ClinInvest 1993;92:2675–82.

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© 1999 by the American College of Rheumatology.