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 Dijkmans2,4,
- C F Allaart1
- 1Leiden University Medical Center, Leiden, The Netherlands
- 2VU Medical Center, Amsterdam, The Netherlands
- 3Sint Franciscus Hospital, Rotterdam, The Netherlands
- 4Jan van Breemen Institute, Amsterdam, The Netherlands
- 5Erasmus 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
- Accepted 22 August 2008
- Published Online First 17 October 2008
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.
Footnotes
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Funding: The BeSt study was supported by the Dutch College of Health Insurances. Schering-Plough and Centocor provided additional funding.
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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.
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Ethics approval: The medical ethics committees of all participating centres approved the study protocol and all patients gave written informed consent before inclusion.
