Hi Naomi
Combination therapy where two or more drugs are used together as part of a treatment plan have been shown to be more effective than a single DMARD. NICE sets out guidelines for the use of Combination Therapy in patients with Rheumatoid Arthritis. From my experience all authorities are required to follow these guidelines which are considered to be 'best practice'. There are differences in procedure throughout the country but on the whole consultants within the NHS try to adopt best practice. There are two entirely different methods of Combination Therapy in use; the step up method and the step down method. Research has shown that patient outcomes are very similar and each approach has its pros and cons. One is not more successful than another.
To outline, in Scotland the method used by some rheumatologists appears to be the step down approach. Several DMARDs (usually Methotrexate, Sulfasalazine and Hydroxychloroquine) are combined at the outset to hit the disease hard and then they are reduced down over time if the disease is stabilised. Good results can be had, but equally it could mean over-treating the condition with drugs that are known to be highly toxic and can have serious side effects even when used individually; many people respond very well and can be controlled on one of these drugs alone. If problems do arise it may be very unclear which of the three drugs is causing the problem and consequently all three have to be stopped and re-started gradually.
In England and Wales the step up method is generally adopted. Many newly diagnosed patients will be given one drug initially. Methotrexate is the gold standard drug used in the treatment of RA and this is the one recommended in the NICE guidelines as the 'anchor' drug for combination therapy. Other drugs such as sulphasalasine, hydroxychloroquine, or similar can then be added, over a period of time, as part of the combination. One of the reasons for adding the drugs in slowly is so that the disease and efficacy of the drugs can be adequately monitored. If side effects develop it can be tricky to know which particular drug is causing the problem if the guidelines aren't followed. Often patients respond well to methotrexate and the disease is brought under control without additional drugs being introduced. The periods of waiting seem quite long but the drugs do act slowly in the build up phase and hence the reason for this. The outcomes need to be carefully monitored at each stage to ensure not only the efficacy of the drugs used but also the effects on other organs such as the liver and kidneys. This provides a more balanced approach to an individual's patients requirements.
Doctors in England and Wales are very much up to speed in modern rheumatology medicine and much of the research into combination therapy was undertaken by professors and reputable physicians in England! Only recently Professor Emery, a highly acclaimed rheumatologist in Leeds, has gone one step further with the trials into the early use of Enbrel (Etanercept) and Methotrexate.
Success of DMARDs between individuals is very difficult to quantify. We each have different profiles and tolerances and therefore individual outcomes to each of the drugs we are given. These amongst other factors make Rheumatoid Arthritis difficult to treat.
I guess Naomi it was particularly difficult in your case because of the side effects ... imagine if you'd been on two or three drugs at once! You also have to take account of the fact that as individuals we each have a different level of disease. What is easily controlled in one person may be much more difficult in someone with severe or aggressive disease. There's no 'one size fits all' where RA is concerned!
Hope that helps
Lyn x
