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Aktuelle Rheumatologie 2001; 26(4): 146-158
DOI: 10.1055/s-2001-17204
ORIGINALARBEIT
© Georg Thieme Verlag Stuttgart · New York

Kombinationstherapie der rheumatoiden Arthritis: Update 2001[1]

Combination Therapy for Rheumatoid Arthritis: Update 2001H. Menninger
  • Medizinische Klinik 1 im Fachkrankenhaus, BRK Rheuma Zentrum, Bad Abbach
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Publication History

Publication Date:
17 September 2001 (online)

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Zusammenfassung

Für mehrere basistherapeutische Kombinationen ist ihre Überlegenheit gegenüber einfacheren Therapieschemata wie die Monotherapie nun aufgrund neuer Publikationen gut belegt. Dies gilt für die Dreifachkombination Methotrexat + Sulfasalazin + Hydroxychloroquin, die bei einem unausgewählten Krankengut ohne Selektion spezifischer Prognosemerkmale in einem dynamischen, den klinischen Anforderungen nahekommenden Design getestet wurde (Calgüneri 1999; Möttönen 1999); ferner gilt dies für die inzwischen bei MTX-Versagern getestete Kombination von Methotrexat + Leflunomid gegen mono-Methotrexat (Kremer 2000) und die Kombination von MTX mit TNFα-blockierenden Substanzen, die ebenfalls nach ungenügendem Ansprechen auf eine vorherige Monotherapie mit MTX ausführlich untersucht wurden. Darüber hinaus gibt es mehrere klinisch bewährte gegenseitige Kombinationen von Methotrexat, Azathioprin, Chloroquinderivaten, Sulfasalazin und Ciclosporin. Die meisten Studien mit starrem Design zeigen jedoch keine eindeutigen Vorteile der jeweiligen Kombination gegenüber den Einzelsubstanzen, was z. T. durch die erheblichen methodischen Schwierigkeiten erklärt werden kann. Dies gilt auch für die viel versprechende Zweifachkombination von intramuskulärem Gold mit Chloroquin oder mit Methotrexat sowie für die bei therapierefraktärer rheumatoider Arthritis eingesetzte Dreifachkombination von Methotrexat oder von Cyclophosphamid mit Azathioprin plus Chloroquinderivat. Diese Dreifachkombinationen werden in therapierefraktären schwerst verlaufenden Einzelfällen eingesetzt, obwohl ihre Überlegenheit gegenüber einfacheren Therapieschemata studienmäßig noch nicht mit der gewünschten Klarheit belegt ist.

Combination Therapy for Rheumatoid Arthritis: Update 2001

The advantages of several DMARD combinations have been clearly demonstrated in recent well-controlled studies. The triple combination of methotrexate + sulfasalazine + hydroxychloroquine has been proved superior in groups of patients not selected for certain disease patterns or prognostic factors, if compared to less complex DMARD regimens (Calgüneri 1999; Möttönen 1999). Furthermore, in patients not sufficiently responding to methotrexate alone, the combinations of that DMARD with leflunomide (Kremer 2000) or with TNFα-blocking agents yielded surprising improvements and even remissions (Weinblatt 1999, Kremer 2000, Maini 1998, Lipsky 1999 and 2000). In addition, several mutual combinations of methotrexate, azathioprine, chloroquine derivatives, sulfasalazine and ciclosporine have been used in studies giving valuable clinical results. Most clinical studies with a stringent design, however, were unable to exhibit clear advantages of combinations if compared with DMARDs used in monotherapy. This obstacle may in part be explained by the difficulties inherited in rigid study designs and does not entirely exclude the value of such combinations. This applies, for instance, to the combination of intramuscular gold with chloroquine derivatives or with methotrexate and to the triple combination of methotrexate or cyclophosphamide with azathioprine and with a chloroquine derivative. These triple combinations are still used in refractory rheumatoid arthritis although studies reported give only hints regarding superiority.

1 Der Artikel basiert auf einem Vortrag, der während der 29. Tagung der Deutschen Gesellschaft für Rheumatologie (Aachen, 13. - 16. September 2000) auf einem Satellitensymposium gehalten wurde („Nicht alles, was glänzt, ist Gold: Goldtherapie - aktueller denn je”; Vorsitz: R. Rau und H. Menninger).

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1 Der Artikel basiert auf einem Vortrag, der während der 29. Tagung der Deutschen Gesellschaft für Rheumatologie (Aachen, 13. - 16. September 2000) auf einem Satellitensymposium gehalten wurde („Nicht alles, was glänzt, ist Gold: Goldtherapie - aktueller denn je”; Vorsitz: R. Rau und H. Menninger).

Prof. Dr. med. H.  Menninger

Medizinische Klinik 1 im Fachkrankenhaus
BRK Rheuma Zentrum

Kaiser Karl V.-Allee 3
93074 Bad Abbach