Drug-free remission, functioning and radiographic damage after 4 years of response-driven treatment in patients with recent onset rheumatoid arthritis
Sjoerd M Van Der Kooij 1*, Yvonne PM Goekoop-Ruiterman 2, Jeska K De Vries-Bouwstra 3, Melek Guler-Yuksel 2, Aeilko H Zwinderman 4, Pit JSM Kerstens 5, Peter AHM Van Der Lubbe 6, Willem M De Beus 7, Bernard AM Grillet 8, Karel Ronday 9, Tom WJ Huizinga 2, Ferdinand C Breedveld 10, Ben AC Dijkmans 11 and Cornelia F Allaart 1
1 LUMC, Netherlands
2 Leiden University Medical Center, Netherlands
3 VUmc, Netherlands
4 AMC, Netherlands
5 Jan van Breemen, Netherlands
6 Vlietland Hospital, Netherlands
7 MCH, Netherlands
8 Hospital Zeeuws Vlaanderen, Netherlands
9 Haga Hospital, Netherlands
10 University Hospital Leiden, Netherlands
11 VU Medical Center, Netherlands
* To whom correspondence should be addressed. E-mail: smvanderkooij{at}lumc.nl.
Accepted 10 July 2008
 | Abstract |
|---|
Objectives: To compare the occurrence of drug-free remission, functional ability and radiological damage after 4 years of response-driven treatment according to 4 different treatment strategies for rheumatoid arthritis (RA).
Methods: Patients with recent onset, active RA (n=508) were randomized to 4 different treatment strategies: (1) sequential monotherapy; (2) step-up combination therapy; (3) initial combination therapy with prednisone; and (4) initial combination therapy with infliximab. Treatment was adjusted based on three-monthly disease activity score (DAS) assessments, aiming at a DAS 
2.4. From the third year, patients with a sustained DAS <1.6 discontinued treatment.
Results: In total, 43% of patients were in remission (DAS <1.6) at 4 years, and 13% were in drug-free remission: 14, 12, 8 and 18% of patients in groups 1-4, respectively. Absence of anti-cyclic citrullinated peptide antibodies, male gender and short symptom duration were independently associated with drug-free remission. Functional ability and remission were maintained in all 4 groups with the continuation of DAS-driven treatment, without significant differences between the groups. Significant progression of joint damage was observed in 38% and 31% of patients in groups 3 and 4 versus 51% and 54% of patients in groups 1 and 2 (P<0.05, group 4 versus groups 1 and 2, group 3 versus group 2).
Conclusions: In patients with recent onset active RA, drug-free remission was achieved in up to 18% of patients. DAS-driven treatment maintained clinical and functional improvement, independent of the treatment strategy. Joint damage progression remained significantly lower after initial combination therapy compared with initial monotherapy.
