THE USE OF ANTIMALARIALS IN COMBINATION WITH OTHER DISEASE-MODIFYING AGENTS IN RA - THE BRITISH-EXPERIENCE

Antimalarial drugs are effective disease modifying agents in RA with a low incidence of serious toxic effects. Recently, combinations of sec ond-line agents have been used in RA in attempts to treat patients wit h no response to a number of single agents, or suboptimal response to a single agent. Combinations of drugs have been selected for maximum e fficacy and minimum toxicity, but clinical trials are difficult to des ign and interpret. In particular, ensuring adequate power to detect sm all differences in response poses a major problem. Antimalarials are a n attractive choice for combination therapy due to their efficacy, mec hanisms of action and toxicity profile. In this review, the evidence f or the use of antimalarials in combination in RA is examined. No advan tage has been shown in combining antimalarials with gold, penicillamin e or sulphasalazine compared with monotherapeutic regimens. There is s ome evidence to suggest a beneficial combination of antimalarials with methotrexate, but this is as yet inconclusive. Open non-randomised un controlled studies have shown that antimalarials combined with cytotox ic agents are effective but highly toxic. The authors conclude that th ere is little good evidence to support the introduction of combination second-line drug therapy for RA into widespread therapeutic use.