CLINICAL AND EPIDEMIOLOGICAL RESEARCH

Clinical and radiological efficacy of initial vs delayed treatment with infliximab plus methotrexate in patients with early rheumatoid arthritis

S M van der Kooij¹, S le Cessie¹, Y P M Goekoop-Ruiterman¹, J K de Vries-Bouwstra², D van Zeben³, P J S M Kerstens⁴, J M W Hazes⁵, D van Schaardenburg⁴, F C Breedveld¹, B A C Dijkmans^2,4, C F Allaart¹

¹ Leiden University Medical Center, Leiden, The Netherlands
² VU Medical Center, Amsterdam, The Netherlands
³ Sint Franciscus Hospital, Rotterdam, The Netherlands
⁴ Jan van Breemen Institute, Amsterdam, The Netherlands
⁵ Erasmus Medical Center, Rotterdam, The Netherlands

S M van der Kooij, Department of Rheumatology C-01-R, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands; smvanderkooij{at}lumc.nl

Objectives: To compare the clinical and radiological efficacy of initial vs delayed treatment with methotrexate (MTX) and infliximab (IFX) in patients with recent onset rheumatoid arthritis (RA).

Methods: In a post hoc analysis of the BeSt study (for Behandel Stratagieen, Dutch for treatment strategies), 117 patients who started initial MTX+IFX were compared with 67 patients who started MTX+IFX treatment after failing (disease activity score (DAS)>2.4; median delay to IFX: 13 months) on 3 traditional DMARDs. If the DAS remained >2.4, the protocol dictated IFX dose increases to 6, 7.5 and 10 mg/kg. In case of a DAS 2.4 for 6 months, IFX was tapered and finally stopped. We aimed to correct for allocation bias using propensity scores. Functional ability was measured by the Health Assessment Questionnaire (HAQ), radiological progression by Sharp/van der Heijde scoring (SHS).

Results: Baseline differences between the initial and delayed groups were no longer significant after propensity score adjustment. At 3 years after baseline, patients treated with initial MTX+IFX experienced more improvement in HAQ over time and were less likely to have SHS progression than patients treated with delayed MTX+IFX (p = 0.034). At 2 years after IFX initiation, more patients in the initial group compared with the delayed group could discontinue IFX after a good response (56% vs 29%, p = 0.008).

Conclusions: The results of this post hoc analysis suggest that using MTX+IFX as initial treatment for patients with recent onset RA is more effective than reserving MTX+IFX for patients who failed on traditional DMARDs, with more HAQ improvement over time, more IFX discontinuation and less progression of joint damage.

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