EARLY AGGRESSIVE THERAPY FOR RA RECOMMENDED

June 28, 2010 — Early, aggressive use of disease-modifying antirheumatic drugs (DMARDs) is recommended for patients with rheumatoid arthritis (RA), according to the results of a randomized controlled trial reported online June 24 in Arthritis Research and Therapy.

"Early therapy with combinations of conventional DMARDs has been shown to retard the radiologic progression of RA for a period of up to 5 years, but until now the effects of initial aggressive DMARD therapy on radiologic prognosis after that were unknown," said lead author Vappu Rantalaiho, MD, from Tampere University Hospital in Finland, in a news release. "We've shown that even after 11 years, early and aggressive therapy achieves excellent results for most patients."

The study goal was to assess radiologic progression beyond 5 years in 199 patients with early active RA initially treated with a combination of 3 DMARDs or with DMARD monotherapy. Participants were initially assigned to treatment with a combination of methotrexate, sulfasalazine, and hydroxychloroquine with prednisolone (FINRACo), or treatment with a single DMARD (initially sulfasalazine) with or without prednisolone (SINGLE). The drug-treatment strategy after 2 years still targeted remission, but drug choice became unrestricted.

Outcome measures were Larsen score of hand and foot radiographs analyzed at baseline, 2, 5, and 11 years, and radiographic findings of large joints at 11 years. Radiographs of hands and feet were available at baseline and at 11 years for 65 patients in the FINRACo group and for 65 patients in the SINGLE group.

For the FINRACo group, mean change in Larsen score from baseline to 11 years was 17 (95% confidence interval [CI], 12 - 26) compared with 27 (95% CI, 22 - 33) in the SINGLE group (P = .037). There were no erosive changes in large joints at 11 years in 87% of the patients in the FINRACo group (95% CI, 74 - 94) and in 72% (95% CI, 58 - 84) of the patients in the SINGLE group.

"Targeting to remission with tight clinical controls results in low radiologic progression in most RA patients," the study authors write. "Patients treated initially with a combination of DMARDs have less long-term radiologic damage than do those treated initially with DMARD monotherapy."

Limitations of this study include a trend toward a lower Larsen score at baseline in the FINRACo group completers vs the SINGLE group completers.

"Probably the most important precondition to our excellent results in most patients was the active treatment policy aiming at remission at all time points," Dr. Rantalaiho concluded. "Our results emphasize the importance of early remission for long term outcome. In the present study, the patients who were in strict remission at 1 year had significantly less radiologic progression throughout the follow-up than the patients who were not."

The Medical Research Fund of Tampere University Hospital and the Finnish Society for Rheumatology supported this study. The study authors have disclosed no relevant financial relationships.

Arthr Res Ther. Published online June 24, 2010.