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Kombinationsbehandlung von Methotrexat mit DMARDs oder Biologika – Aktueller Stand

Combination therapy using methotrexate with DMARDs or biologics – current status

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Zusammenfassung

Methotrexat (MTX) stellt sowohl für andere DMARDs als auch für Biologika bei der rheumatoiden Arthritis den wichtigsten Kombinationspartner dar. DMARD-Kombinationen kommen in der Regel bei nicht ausreichendem Ansprechen der Starttherapie mit MTX-Monotherapie zum Einsatz. Evidenzbasiert haben sich vor allem die Kombinationen MTX plus Leflunomid, MTX plus Ciclosporin sowie die Triple-Kombination MTX plus Sulfasalazin plus Hydroxychloroquin (ergänzt durch Glukokortikoide) bewährt.

Bei nicht ausreichender Wirkung der DMARD-Kombination sollte MTX mit einem Biologikum kombiniert eingesetzt werden, am häufigsten wird hier bisher zunächst die Kombination MTX plus TNF-Inhibitor verwendet. In Studien weisen allerdings alle Biologika (bis auf Anakinra) in Kombination mit MTX vergleichbare Erfolgsraten auf, auch die Kombinationen MTX plus Abatacept, MTX plus Rituximab und MTX plus Tocilizumab sind somit erfolgsversprechend, was sowohl die klinische als auch die destruktionsbremsende Wirkung einschließt. In Kombination mit MTX wirken Biologika in der Regel besser als in Monotherapie.

Generell gilt für alle genannten Kombinationstherapien, dass die Verträglichkeit nicht wesentlich unter der der Einzelsubstanzen liegt. Dementsprechend sind auch die erforderlichen Kontrolluntersuchungen gleichartig.

Abstract

Methotrexate (MTX) is the most frequently used drug in combination treatment with disease-modifying antirheumatic drugs (DMARDs) and biologics in rheumatoid arthritis. DMARD combinations are usually the second step after unsuccessful MTX monotherapy. Evidence-based combinations of MTX+leflunomide, MTX+cyclosporine and triple combination MTX+sulphasalazine+hydroxychloroquine (complemented by glucocorticoids) showed the best results.

In the case of insufficient response to the DMARD combination, MTX should be used in combination with a biologic. To date, the most frequent biologic treatment is with TNF inhibitors, but studies have shown that all biologics (with the exception of Anakinra) have comparable success rates. The combination of MTX plus abatacept, MTX plus rituximab and MTX plus tocilizumab are very promising, both clinically and in terms of blocking radiological progression. The efficacy of biological therapy is generally better using MTX combination than monotherapy.

The safety of MTX combination treatment with DMARDs is not significantly lower than that of the individual substances; therefore, the required safety controls are also the same.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Vorträge und Beratungstätigkeit für die Firmen Abbott, Bristol Myers Squibb, Essex, Medac, Roche, UCB, Wyeth.

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  1. Rheumatologisches Praxiszentrum St.Bonifatius, St. Bonifatius Str. 5, 81541, München, Deutschland

    K. Krüger

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Krüger, K. Kombinationsbehandlung von Methotrexat mit DMARDs oder Biologika – Aktueller Stand. Z. Rheumatol. 70, 114–122 (2011). https://doi.org/10.1007/s00393-010-0684-3

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