Triple therapy, anyone?

Four months of methotrexate has done me no good, in fact, my feet are getting worse. (OK, it's winter here and really cold, so that may explain part of the deterioration.) I was hoping that there might be a change of tack coming (like, forget the mtx, and I was already looking forward to having a glass, just one glass, of wine...). But last week I went to the rheumie and I'm still on mtx, but she started me on two more drugs for what she called "triple therapy": sulfasalazine and hydroxychloroquine.

Obviously, I haven't seen any positive effects yet, only a terrible lingering bitter taste in my mouth. Oh, and the runs this morning, but that's probably tmi.

I'm trying to be positive, having read that this combination can help in a way that the individual drugs on their own don't. And apparently, toxicity with the combo isn't a big issue.

Can anybody tell me their experiences with this concoction?

I am on MTX and Sulfasalazine. The only thing I have had happen so far is that the psoriasis is cleared off of my hands. I do have the worst heartburn I have ever experienced in my life now. It is constant and nothing so far is helping it. I am hopeful that here soon they will start to help with the pain. I am super happy about my hands. This is the first time in a year that they are not bleeding everyday.

Being newly diagnosed, I am just getting into the full dosage of Sulfasalzine, but it makes me burp a lot. I have been very careful to take it after eating but as the dosage increased, so did the burp situation (in fact, I just burped while writing this). I had issues with heartburn prior to the meds but rarely have any now - I am not sure if it is due to the meds or if it is due to my change in diet (trying to eat nightshade free). My psoriasis is almost gone again (went away once but then stress levels brought it on again) and the pain is better but my feet are still acting up. I have family coming to visit today but have not finished cleaning house as I am working at it smartly and stopping every so often to rest and not hurt myself anymore. Hubby is helping alot today, I think he finally gets that I am hurting and can only do so much, thank Goodness.

I'm hangin'! Thanks for the input. To be honest, I'd be happy if they'd just cut straight to the biologic chase. But for some reason, this is the treatment plan for now. I am tired, sore, depressed and scared. There are erosions in my feet (the only place I have significant problems), and I want the inflammation to stop before I end up in a wheelchair. I know everyone here understands, and I appreciate your support.


Trees, that's helpful: now I understand why the rheumie put me on the other two DMARDs. From the sounds of it, the next move in this chess game may be a biologic.


Hi Seenie, Just caught up with this thread.

Triple therapy, or combination therapy, is common these days. Most research into inflammatory or auto-immune arthritis begins with RA because it is the most commonly seen type of inflammatory arthritis. Rheumies used to treat arthritis by beginning with nsaids, then moving to more aggressive drugs when nsaids failed (typically nsaids, then MTX, then biologics). In this way, they saved the biggest guns for later in treatment when symptoms and complications were more severe. The logic was that since stronger drugs seemed to carry a risk of serious side FX, it was better to put off treatment with dmards until later stages of treatment.

Now, the focus has changed. RA is believed to respond better to early aggressive treatment, meaning, by using the bigger guns first, the potential for developing serious complications of RA is reduced and overall outcomes are improved (fewer erosions, deformities, etc).

Fast-forward in RA research: Benefits are even greater with triple (or even double) therapy than with single therapy. It's an aggressive way of treating arthritis, but surprisingly doesn't seem to increase the risks of side FX over a single therapy regimine. The same logic is being applied to other types of arthritis, including PsA, but little research has been completed on combination therapies and PsA. In RA, some combinations appear to yield better results than others. MTX, sulphasalazine, and plaquenil is a very beneficial combo seen in RA research.

I've been on double therapy (MTX and plaquenil) since late summer with good results in terms of pain relief, IMHO. But my rheumy is delighted as inflammation and swelling seem to be down. My toes that were beginning to curl and deform are back in line and I do have less pain in my lower back, toes, SI joints and a few other joints. This is all very good news, but my expectations were way too high--I wanted total remission, which probably is unrealistic. Still, although my rheumatolgist is pushing for me to discontinue the plaquenil in spring, I am reluctant to alter a plan that seems to be working! I also take Asacol for inflammatory bowel disease, which is a variant of sulphasalazine, so I may be getting some benefit from that, as well.

You can read more about combination therapies here:

Many insurance companies do require at least a trial with MTX before they will consider paying for a biologic. For example, with Medicare, rheumy said, they like for you to do at least a 3 month trial of MTX with failure before they will pay for a biologic. It's interesting that a lower percentage of people on Medicare Part D are using biologics than is true for the general population. I have checked into the cost of simponi to me, and I believe the discrepancy is most likely because of cost to the patient. For example, if I were taking simponi alone (no other drugs at all for any health condition), the cost of simponi to me would be in the neighborhood of $4150/year, with prior approval. That's simply beyond realistic for me, and for many retirees who have only Medicare Part D to rely on for drug coverage.

Hope this helps!

I have only been on mtx for 4 months now and Humira for almost one, as if i didnt feel yucky enough with the mtx alone the humira has added a whole new level of yucky....but they seem to be working, or it was just the cortisone shot that has been making me feel better.

I did talk to my rhumey about the wine issue and he told me that as long as my liver leveles stayed normal he would approve a glass a month but no more, so i splurged on new years and had a glass of champange with my husband and let me tell you I felt so bad for the following 3 days that i have no urge to drink ever again while i am on this medicine, i hadnt started humira at that point so it was just the mtx alone that was making me feel so bad.

Good luck with everything, I hope that you start to see more results!

OK folks! Two months after starting triple therapy, and I *think* I'm seeing results. Which drug is doing it, I don't know. Or maybe it's the combination. Or is it the fact that I've been in a warmer climate for the last 4 weeks? I've been on my feet less? It's so frustrating to figure out what works and what doesn't, because changes are so slow, and it's hard to isolate the variables.

Whatever, I'm enjoying what I'm not feeling! Today's a good day, let's hope for more days like the ones I've been having.

How is everyone else doing?


Hi Seenie! Sorry so long in replying. I have 60 students in my intro Soc. class this semester, and like a dork, I assigned a ten-page essay. AGGGHH So I've been grading essays for the past two weeks. lol Now it's mid-term and here we go again. Anyway...

Glad to hear you are feeling well! Sunshine always always helps me. I feel so much better in spring and summer. Apparently, it's something to do with the angle of the earth and the way the UV rays hit us. Doc wants me off of plaquenil (and I do, too), but we agreed not to do it until this shift...some time around the vernal equinox. Sounds like black magic, huh, but it's absolutely proven that UV rays help psoriatics. I figure being down south closer to the equator probably has a similar effect. I know when we head south for vacation, I feel wonderful.

Whatever it is for you, drugs or sunshine, combination or what, I'm just glad it's working for you. Good to hear you feeling so great!! While you're feeling so well, I could email you some essays to grade...

Stay in touch!

Well, I spoke too soon. Yesterday, my feet were as bad as they've ever been. Maybe the combo isn't working. But then again, we've got a weather change coming through too.

It is so hard to know what does me good and what doesn't!

Byrd, don't email me essays: I've lost my red pen. Darn. LOL


Oh no! I was so hoping that between the combo therapy and the sunshine, you had finally found some relief. I'm really sorry to hear this, Seenie, and hope that you are feeling better by now. Plus, you have good motivation to feel better, since I have finished the essays and will no longer need to send them your way. ;-)

Feeling a bit better today. But then again, I woke up and thought "I just think I'll take two tylenol arthritis instead of my usual one!". So I did. Weather is better today, and feet feel reasonable. I did some cooking this morning, and now I'm off to do errands.

Glad you finished marking those essays, for my sake and yours, Byrd!