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Intensive treatment with methotrexate in early rheumatoid arthritis: aiming for remission. Computer Assisted Management in Early Rheumatoid Arthritis (CAMERA, an open-label strategy trial)

S M M Verstappen¹, J W G Jacobs¹, M J van der Veen², A H M Heurkens³, Y Schenk⁴, E J ter Borg⁵, A A M Blaauw⁶, J W J Bijlsma¹, on the behalf of the Utrecht Rheumatoid Arthritis Cohort study group

¹ University Medical Center Utrecht, Utrecht, the Netherlands
² St Jansdal Hospital, Harderwijk, the Netherlands
³ Meander Medical Center, Amersfoort, the Netherlands
⁴ Diakonessenhuis, Utrecht, the Netherlands
⁵ St Antonius Hospital, Nieuwegein, the Netherlands
⁶ Flevo Hospital, Almere, the Netherlands

Dr J W G Jacobs, University Medical Center Utrecht, Department of Rheumatology & Clinical Immunology, F02.127, PO Box 85500, 3508 GA Utrecht, the Netherlands; j.w.g.jacobs{at}umcutrecht.nl

Background: To investigate whether intensive treatment with methotrexate (MTX) according to a strict protocol and a computerised decision program is more beneficial compared to conventional treatment with MTX in early rheumatoid arthritis.

Methods: In a two-year multicentre open label strategy trial, 299 patients with early rheumatoid arthritis were randomly assigned to the intensive strategy group or the conventional strategy group. Patients in both groups received MTX, the aim of treatment being remission. Patients in the intensive treatment group came to the outpatient clinic once every month; adjustment of the MTX dosage was tailored to the individual patient on the basis of predefined response criteria, using a computerised decision program. Patients of the conventional strategy group came to the outpatient clinic once every three months; they were treated according to common practice. Cyclosporine was added if patients had an inadequate response to maximal tolerated MTX doses.

Results: Seventy six (50%) patients in the intensive strategy group achieved at least one period of remission during the two year trial, versus 55 patients (37%) in the conventional strategy group (p = 0.03). Areas under the curve for nearly all clinical variables were significantly lower—that is, there was a better clinical effect for the intensive treatment group compared with the conventional treatment group.

Conclusion: The results of this study show that it is possible to substantially enhance the clinical efficacy early in the course of the disease by intensifying treatment with MTX, aiming for remission, tailored to the individual patient. Furthermore, participating rheumatologists indicated that the computerised decision program could be a helpful tool in their daily clinical practice.

Abbreviations: ACR, American College of Rheumatology; DMARDs, disease-modifying anti-rheumatic drugs; ESR, erythrocyte sedimentation rate; MTX, methotrexate; NSAIDs, non-steroidal anti-inflammatory drugs; VAS, visual analogue scale

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