A study found that older drugs, such as disease-modifying antirheumatic drugs, or DMARDs, used to treat rheumatoid arthritis, or RA, can be as effective at slowing joint damage as newer, pricier biologic medications.

The study’s researchers acknowledge these findings might be met with skepticism because many believe biologics to be superior.

“Since the appearance of biologic agents in the beginning of this century it has been a general position that these were much better in the treatment of rheumatoid arthritis than the well-known classical and cheap antirheumatic drugs or DMARDs,” says lead author Niels Graudal, MD, a clinical rheumatologist and researcher at Copenhagen University Hospital in Denmark. “I think our results are very surprising.”

Traditional DMARDs include agents like cyclosporine and methotrexate, which have been used for decades to slow the progression of RA, though doctors aren’t always sure why they work. Corticosteroids are hormones that fight inflammation, and biologic agents, which include medications like etanercept, or Enbrel, adalimumab, or Humira, and infliximab, or Remicade, block the chemical signals that spur inflammation.

In Arthritis & Rheumatism, Dr. Graudal and his colleagues reviewed 70 previously published trials that measured the effectiveness of different combinations of RA drugs.

They found that treatment with one DMARD or corticosteroid reduced X-ray evidence of joint destruction between 50 and 65 percent compared to a placebo.

Compared to treatment with a single DMARD alone, joint destruction was reduced between 50 and 84 percent when a corticosteroid or a biologic agent was added.

Two DMARDs given with corticosteroids proved to be as effective as a biologic given with methotrexate.

“The big news is that even a single DMARD is able to stop joint destruction in many patients and on the average, inhibits joint destruction 65 percent compared with no treatment,” Dr. Graudal says. “With a combination of two to three DMARDs and a low dose corticosteroid, you can obtain the same inhibition of joint destruction as you can with a biologic agent plus methotrexate.”

Biologics are more expensive than other medications because they are genetically engineered. Researchers say while they can be very helpful to patients who don’t respond to DMARDs, they believe their study shows there are equally affordable options for most other patients.

Dr. Graudal says he hopes the study findings reassure doctors and patients that are giving and getting a more traditional course of medicine.

“Many rheumatologists who treat their patients with old fashioned DMARDs might have been nagged by a feeling that a better biologic treatment was withheld from their patients for economical reasons only,” Dr. Graudal says.

David Pisetsky, MD, PhD, a professor of Medicine and Immunology at Duke University Medical Center in Durham, N.C., agrees with the study’s findings.

“While biological agents such as TNF blockers are effective in the treatment of rheumatoid arthritis, other drugs as well as drug combinations can produce similar benefits,” Dr. Pisetsky says. “The important goal of therapy is to reduce disease activity and hopefully achieve remission. This goal can be accomplished in many different ways, with the use of biologicals one of many approaches that are currently available.”

But Daniel E. Furst, MD, a professor of rheumatology at the University of California, Los Angeles, says while they might not have been included in this research, there are studies that show biologics improve radiographs more than non biologics. And he says the numbers in this study just don’t add up for him.

“They say that there is a relative effect of 50 to 65 percent using a DMARD versus a placebo. And then the next sentence they say if you use a DMARD and biologics you get an additional 50 to 80 percent improvement compared to a single DMARD. So their conclusion that there is no difference between single and multiple DMARDS doesn’t hold up,” Dr. Furst says. “It’s hard for me to understand their conclusion which says that everything is the same.”