Background Intra-articular glucocorticoid-injections (IACIs) have been used widely for decades in the treatment of rheumatoid arthritis (RA). However, very limited amount of data exist on their impact (1).
Objectives We aimed to study the effects of missing IACIs in otherwise intensively treated early RA patients.
Methods 99 patients with active early RA were enrolled into a investigator-initiated, randomized, double-blind, trial, the NEO-RACo trial. They were treated with an intensified combination of methotrexate, sulfasalazine, hydroxychloroquine, low-dose prednisolone, and IACIs for 2 years, and randomized to receive either infliximab or placebo for the initial 6 months. At all times, treatment was targeted to modified American College of Rheumatology (ACR) remission and according to protocol IACs had to be given to every swollen joint as well as drug doses increased, if RA was active. Patients were assessed clinically 11 times during the first 12 months and thereafter every three months. Quality of life was assessed with the Short-Form 36 questionnaire at 0, 8, 12 and 24 months. Radiographs of the hands and feet were taken at baseline and at 24 months.
Retrospectively, patients were scored at each of the 15 study visits 0.2 points if 1–2 small swollen joints were not given IACIs, and 0.4 points if >2 small or ≥1 large swollen joints were not injected. However, points were not given if at least 2 ml of glucocorticoid suspension (methylprednisolone or triamcinolone hexacetonide) per visit were used. Patients were divided into tertiles according to their cumulative score for missed injections (CSMI) and linear trend between the tertiles was tested.
Results At 24 months, higher CSMI was associated with lower DAS28 (p=0.021) and strict remission rates (p=0.005), and higher DAS28 AUC (p<0.001). At 24 months, DAS28 remission rates were 90%, 93% and 76% in tertiles of CSMI (p=0.081), and strict remission rates were 74%, 77% and 39% in tertiles of CSMI (p=0.005). Quality of life was lower in the third tertile than in the first (p<0.001) and the second tertiles (p=0.020). No significant differences were observed in radiological progression.
Conclusions Neglecting IACIs into swollen joints is associated with higher disease activity over time, lower remission rates and lower quality of life in early RA. Hence, IACIs should be used as an integral part of the targeted treatment of early RA.
Furtado RN, Oliveira LM, Natour J. Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study. J Rheumatol 2005 Sep;32(9):1691-1698.
Leirisalo-Repo M, Kautiainen H, Laasonen L, Korpela M, Kauppi MJ, Kaipiainen-Seppanen O, et al. Infliximab for 6 months added on combination therapy in early rheumatoid arthritis: 2-year results from an investigator-initiated, randomised, double-blind, placebo-controlled study (the NEO-RACo Study). Ann Rheum Dis 2013 Jun;72(6):851-857.
Acknowledgements The authors would like to thank all participating patients, study nurses, and co-investigators.
Disclosure of Interest None declared