Background The treatment of rheumatoid arthritis (RA) should aim at remission. A substantial part of the patients may achieve this target when an initial treatment with a combination of disease modifying anti-rheumatic drugs (DMARD) is used. Initial biologics may induce a faster response than traditional DMARDs, but their role on long-term outcomes is ambiguous .
Objectives To study whether the addition of infliximab to aggressive, targeted initial combination-DMARD treatment produces extra benefit in the long-term outcomes in patients with early RA.
Methods A total of 99 patients with early (<1 year), DMARD-naïve RA were treated with a combination of methotrexate (max 25mg/week), sulfasalazine (max 2g/day), hydroxychloroquine (35mg/kg/week) and prednisolone (7.5mg), and randomized to blindly receive either infliximab (FIN-RACo+INFL) or placebo (FIN-RACo+PLA) infusions at weeks 4, 6, 10, 18, and 26. After 2 years the treatment strategies became unrestricted, but throughout the follow-up the treatment goal was strict ACR remission. At 5 years the clinical and radiographic outcomes, as well as the treatments used were assessed.
Results A total of 94 patients (95%) were followed up for 5 years, 46 in the FIN-RACo+INFL and 48 in the FIN-RACo+PLA group. The proportion of patients in strict ACR remission was 59% (95% CI 43 to 73%) and 60% (95% CI 45 to 74%) (p=0.87), and in DAS28 remission 83% (95% CI 69 to 92%) and 88% (95% CI 75 to 95%) (p=0.51), in the FIN-RACo+INFL and FIN-RACo+PLA groups, respectively. The corresponding mean (SD) total Sharp/van der Heijde scores at 5 years were 5 (8), and 5 (7), while the mean changes in it from baseline to 5 years were 2 (95% CI 0 to 4) and 4 (95% CI 2 to 5) (p=0.13). From 2 to 5 years, the median (IQR) cumulative prednisolone doses were 1.4 (0.7-4.1) and 1.2 (0.8-3.3) mg/day in the FIN-RACo+INFL and in the FIN-RACo+PLA groups (p=0.92), respectively, while during the total follow-up of 5 years, the respective median (IQR) numbers of intra-articular glucocorticoid injections were 4 (1-15) and 7 (3-12) (p=0.54). After 6 months any biologic drug was initiated to 4 (9%) and 8 patients (17%) (p=0.36), and the median (range) number of synthetic or biologic DMARDs used was 3 (3-10) and 3 (3-11), in the FIN-RACo+INFL and FIN-RACo+PLA groups, respectively.
Conclusions In early RA, targeted treatment with a combination of DMARDs and prednisolone induces remission and minimises radiographic progression in most patients at 5 years; adding initial infliximab for 6 months does not improve these outcomes or reduce the need of consequent treatment.
 Klarenbeek et al. The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study. Ann Rheum Dis 2011;70:1039-46.
Disclosure of Interest None Declared
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.