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Clinical and radiological efficacy of initial vs delayed treatment with infliximab plus methotrexate in patients with early rheumatoid arthritis
  1. S M van der Kooij1,
  2. S le Cessie1,
  3. Y P M Goekoop-Ruiterman1,
  4. J K de Vries-Bouwstra2,
  5. D van Zeben3,
  6. P J S M Kerstens4,
  7. J M W Hazes5,
  8. D van Schaardenburg4,
  9. F C Breedveld1,
  10. B A C Dijkmans2,4,
  11. C F Allaart1
  1. 1
    Leiden University Medical Center, Leiden, The Netherlands
  2. 2
    VU Medical Center, Amsterdam, The Netherlands
  3. 3
    Sint Franciscus Hospital, Rotterdam, The Netherlands
  4. 4
    Jan van Breemen Institute, Amsterdam, The Netherlands
  5. 5
    Erasmus Medical Center, Rotterdam, The Netherlands
  1. 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

Abstract

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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Footnotes

  • Funding: The BeSt study was supported by the Dutch College of Health Insurances. Schering-Plough and Centocor provided additional funding.

  • Competing interests: CFA and FCB have received lecture fees from Schering-Plough; BAD has received funds for research and lecture fees from Schering-Plough. The authors were responsible for the study design, the collection, analysis and interpretation of all data, the writing of this article and the decision to publish.

  • Ethics approval: The medical ethics committees of all participating centres approved the study protocol and all patients gave written informed consent before inclusion.

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