True about combination therapy with anakinra and infliximab in rheumatoid arthritis patients is:

Ans. A. Combination should be avoidedRef: Harrison's Principles of Internal Medicine 19th/ed, p2147Explanation# Option a: Anakinra (IL 1 antagonist) and infliximab (anti-TNF) should not be combined.# Both agents restrict inflammatory process markedly and lead to high rate of serious infections.# This finding is observed in trials that used this regimen.# New strategy in treatment of RA focuses on several goals:1. Early, aggressive therapy to prevent joint damage and disability.2. Frequent modification of therapy and use of combination therapy where appropriate.3. Individualization of therapy, to maximize response and minimize side effects;4. Achieving, remission of clinical disease activity.# Preferred first line drug as monotherapy in moderate to severe RA: Methotrexate# Effective combinations include:# Methotrexate, sulfasalazine, and hydroxychloroquine (oral triple therapy);# Methotrexate and leflunomide;# Methotrexate plus a biological (e.g. methotrexate and infliximab an anti-TNF agent; methotrexate + Etanercept is equivalent to oral triple therapy options b and d)# Early RA (<6 months of disease duration)# Started with methotrexate - switch or add DMARD therapy after 3 months of worsening or persistent moderate/high disease activity - If disease still persists after 3 months of intense DMARD therapy, add a biologic agent.# Oral triple therapy (hydroxychloroquine, methotrexate, and sulfasalazine) is a reasonable first step for the treatment of early RA, including its use as a step-up strategy where treatment is initiated with methotrexate alone and then combined at 6 months with hydroxychloroquine and sulfasalazine if the disease is not adequately controlled.# Patients with established RA.# Treatment with a biologic agent or aggressive combination DMARD therapy was also recommended as initial therapy in certain patients with high disease activity and poor prognosis.