Background Tight control with treat-to-target as treatment strategy is widely used to prevent a severe outcome of rheumatoid arthritis (RA). Our CAMERA (Computer Assisted Management of Early Rheumatoid Arthritis)1 study demonstrated the effectiveness of tight control compared to a traditional treatment strategy. However, there was room for improvement. In the second CAMERA study (CAMERA-II)2, the effect of addition of 10 mg of prednisone from start to the MTX-based tight control strategy (MTX+pred) was compared with that of the addition of a placebo (MTX+plac). In both trials, the most intensive strategy arm had the largest favorable effect on disease activity. However, the effect of tight control schedules on the quality of life (QoL) of patients has not been addressed sufficiently.
Objectives To examine in early RA patients if QoL is affected by a tight control treatment strategy and if additional prednisone initiated from start modifies this (if any) effect.
Methods In the two CAMERA trials, patients with early rheumatoid arthritis (RA, disease duration <1 year, DMARD naïve) had been randomized to a methotrexate (MTX)-based tight control strategy vs. usual care (CAMERA) and (CAMERA-II) to a MTX-based tight control strategy with either 10 mg/d prednisone or placebo. In both studies, the more intensive strategy resulted in lower disease activity. To assess QoL, the “Influence of Rheumatic Diseases on General Health and Lifestyle” questionnaire (IRGL) was used. The IRGL addresses three domains: Physical function (scales: Mobility, Self-Care and Pain), Psychological well-being (scales: Depressive mood, Cheerful mood and Anxiety) and Social well-being (scales: Nr. neighbours, Nr. friends, Potential support, Actual support and Mutual visits). The scale Impact of the rheumatic disease on daily life consisting of 6 subscales was also assessed. Baseline and 1 and/or 2 year measurements were analysed with regression analyses with the IRGL (sub)scales as dependent variables and treatment strategy and disease activity (DAS28) as independent variables, correcting for baseline values of each scale and possible confounders (gender, age, rheumatoid factor status).
Results A decrease in DAS28 was associated with improvement in most QoL (sub)scales (56% of regression coefficients p<0.05), but there was no clear association between either of the treatment strategies and QoL (96% of the regression coefficients p≥0.05).
Conclusions No independent effect of the specific tight control strategies on QoL was found, but there was a disease activity related effect. Thus the inclusion of prednisone in a tight control strategy or frequent outpatient visits did not negatively influence QoL.
Verstappen SM et al. Intensive treatment with methotrexate in early rheumatoid arthritis: aiming for remission. Computer Assisted Management in Early Rheumatoid Arthritis (CAMERA, an open-label strategy trial). Ann Rheum Dis 2007;66:1443-9.
Bakker MF et al. Low-dose prednisone inclusion in a Methotrexate-Based, Tight Control Strategy for Early Rheumatoid Arthritis. A Randomized Trial. Ann Intern Med 2012;156:329-39.
Disclosure of Interest None Declared
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