Initial combination therapy has been shown to be superior to step-up combination therapy in groups of RA patients; however, these findings are difficult to reconcile with the observation that many RA patients will have complete remission of disease on methotrexate alone. Practice patterns tend to emphasize initial treatment with methotrexate monotherapy, followed by the addition of other agents in combination for those with inadequate responses. However, which agents (biologics vs. non-biologics) to add has not been studied head to head in an untreated population demonstrating inadequate response to methotrexate. Here, van Vollenhoven at al. (Lancet 2009; 374: 459) report the findings of the Swefot (short for Swedish Pharmacotherapy) Trial, exploring the efficacy of adding the TNF inhibitor infliximab to methotrexate vs. adding sulfasalazine + hydroxychloroquine in RA patients who have not rapidly responded to methotrexate monotherapy.
http://www.hopkins-arthritis.org/arthritis-news/2009/swefot-trial-suggests-adding-tnf-inhibitor.html