Background Initiation of DMARD-therapy in the ‘window of opportunity’ is thought to result in more effective modification of the processes underlying Rheumatoid Arthritis (RA).
Objectives We questioned whether this effect is true or hyped and therefore performed a systematic literature review.
Methods Medical literature databases up to June 2012 were systematically reviewed for cohort studies and randomized controlled trials reporting outcome data of early RA in relation with symptom duration at treatment initiation. The quality of these studies was assessed by two independent reviewers using a criteria scoring system of 15 items. Studies were dichotomized with the median score (79%) as cut-off. Best-evidence synthesis was applied to determine the level of evidence per outcome category. A meta-analysis was performed on the studies reporting on achieving DMARD-free sustained remission (the reverse of disease persistency).
Results Out of 836 screened articles, 18 fulfilled the selection criteria and were not duplicates. Nine were scored as high-quality. Remission (various definitions) and radiographic progression were frequently studied outcomes. There was strong evidence for an association between symptom duration and radiographic progression. A meta-analysis on datasets evaluating DMARD-free sustained remission showed that symptom duration was independently associated with such remission both univariable and multivariable after adjustment of age, sex, treatment, rheumatoid factor and erythrocyte sedimentation rate; HR 0.989 (95%CI 0.983-0.995) per week increase in symptom duration (see figure 1 ). A moderate level of evidence was observed for studies on various other remission outcomes.
Conclusions There is strong evidence that prolonged symptom duration is associated with radiographic progression. Furthermore, symptom duration is associated with disease persistency in a meta-analysis, supporting the presence of a ‘window of opportunity’-effect.
Disclosure of Interest None Declared
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