Early RA: biologic-first raised remission by about 60%, but methotrexate-first still stands

The edition in brief

Today's rheumatology edition ends on first-line treatment in early rheumatoid arthritis. A meta-analysis of 29 randomised trials and 13,387 methotrexate-naive patients (Rheumatology, 1 October) found that starting a biologic or targeted synthetic DMARD with methotrexate raised DAS28 remission at six months compared with methotrexate alone (RR 1.62, 95% CI 1.39 to 1.89), with larger gains in trials with higher disease activity and more rheumatoid factor-positive patients. As monotherapy, only tocilizumab and JAK inhibitors beat methotrexate. Guidelines still start with methotrexate, and cost and safety matter, so the practical change is faster escalation for high-risk patients who are not responding. A Japanese multicentre cohort of 64 patients with EGPA found that starting mepolizumab within three months of induction was associated with more remission at one year (69% vs 27%) and less organ damage; the design was observational and small. The CLOAK trial of 120 people with knee osteoarthritis found three months of colchicine did not improve pain, function or effusion, despite lowering inflammatory markers. Three-year pooled data on bimekizumab in 1,112 people with psoriatic arthritis showed sustained responses across joints, entheses, skin and nails. The pearl is weekly methotrexate.