Work group recommendations: 2002 Exercise and Physical Activity Conference, St. Louis, Missouri/Session II, The Problems and Challenges of Inactivity

Methotrexate Dosage Reduction Upon Adalimumab Initiation: Clinical and Ultrasonographic Outcomes from the Randomized Noninferiority MUSICA Trial

OBJECTIVE

To examine the clinical and ultrasonographic (US) outcomes of reducing methotrexate (MTX) dosage upon initiating adalimumab (ADA) in MTX-inadequate responders with moderately to severely active rheumatoid arthritis (RA).

METHODS

MUSICA (NCT01185288) was a double-blind, randomized, parallel-arm study of 309 patients with RA receiving MTX ≥ 15 mg/week for ≥ 12 weeks before screening. Patients were randomized to high dosage (20 mg/week) or low dosage (7.5 mg/week) MTX; all patients received 40 mg open-label ADA every other week for 24 weeks. The primary endpoint was Week 24 mean 28-joint Disease Activity Score based on C-reactive protein (DAS28-CRP) to test for noninferiority of low-dosage MTX using a 15% margin. US images were scored using a 10-joint semiquantitative system incorporating OMERACT definitions for pathology, assessing synovial hypertrophy, vascularity, and bony erosions.

RESULTS

Rapid improvement in clinical indices was observed in both groups after addition of ADA. The difference in mean DAS28-CRP (0.37, 95% CI 0.07-0.66) comparing low-dosage (4.12, 95% CI 3.88-4.34) versus high-dosage MTX (3.75, 95% CI 3.52-3.97) was statistically significant and non-inferiority was not met. Statistically significant differences were not detected for most clinical, functional, and US outcomes. Pharmacokinetic and safety profiles were similar.

CONCLUSION

In MUSICA, Week 24 mean DAS28-CRP, the primary endpoint, did not meet non-inferiority for the low-dosage MTX group. Although the differences between the 2 MTX dosage groups were small, our study findings did not support routine MTX reduction in MTX inadequate responders initiating ADA.

Exercise: An important component of treatment in the idiopathic inflammatory myopathies

Resistive exercise is controversial for patients with idiopathic inflammatory myopathies. This paper provides an update on exercise and clinical assessment in these patients. The few published studies on this topic report unchanged disease activity from a variety of exercise regimens in patients in all stages of disease. Reduced disability was achieved in patients with polymyositis and dermatomyositis. In one study a slightly reduced impairment was reported in patients with inclusion body myositis, while in another study no objective reduction of disability could be detected. An increasing number of valid and reliable outcome measures are available for patients with polymyositis and dermatomyositis, but for patients with inclusion body myositis reliable and sensitive outcome measures are still needed.