Background Combination therapy with disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids(GCs) or biological agents is superior in achieving clinical response and preventing joint damage compared to DMARD monotherapy in patients with early rheumatoid arthritis (RA).
Objectives To compare initial DMARD combination therapy with steroids (ICTS) with DMARD monotherapy (IMT) on the radiologic evolution of patients with early RA over a 2 year treatment period, applying tight control (TC) in daily practice.
Methods 74 DMARD-naïve early RA patients received ICTS or IMT in a TC setting, based on the expert opinion of their rheumatologist (n=2) after informal evaluation of prognostic factors. Demographics were registered at baseline and the following clinical characteristics were obtained at baseline, year 1 and year 2: swollen/tender joint counts (TJC, SJC, TJC28 and SJC28), global assessment scores ( PGA, PhGA, pain and fatigue), Health assessment questionnaire ( HAQ), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) status. Disease activity score based on CRP status (DAS 28(CRP)), EULAR DAS response, clinically meaningful HAQ response, DAS change and HAQ change were calculated from these parameters. Remission was defined as a DAS28 (CRP) score below 2,6. Baseline, year 1 and year 2 X-rays of hands and feet were scored according to Sharp/van der Heijde by 3 readers in consensus: 2 experienced musculoskeletal radiologists (LL and GVDS) and 1 clinical researcher (DDC). Rapid radiographic progression (RRP) was defined as total Sharp score (TSS) of >5 units/year. The mean change in TSS and proportion with RRP were compared between groups.
Results At baseline, joint scores and PhGA were significantly higher in the ICTS group. Thus ICTS patients were perceived to have a higher level of RA severity compared with IMT patients.
At year 1, both treatment groups achieved 50% remission. At year 2, 37% of IMT and 60% of ICTS patients were in remission, despite ICTS patients having a more severe RA profile at baseline.
RRP was found in 4/74 patients at year 1: 3 IMT and 1 ICTS patient. Remarkably, 3 of these 4 patients had no radiographic progression in the second year. 5 Other patients had RRP in the second year: 4 IMT and 1 ICTS patient. 4 Notably young female IMT patients were initially treated with SSZ monotherapy, 2 of which because of pregnancy wish. These patients developed RRP in the second year.
Conclusions In a TC setting, ICTS appears to be more effective than IMT in achieving remission and preventing RRP in the daily practice of a Belgian academic hospital over 2 years. Furthermore, risk on RRP is underestimated in certain patient groups which is translated in conservative therapy choices.
References Verschueren P, Esselens G, Westhovens R. (2008) Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early rheumatoid arthritis. Rheumatology (Oxford) 47(1):59-64
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.