Objectives Objective of this study was to investigate whether the initial treatment strategy that included triple DMARD therapy or methotrexate monotherapy differed at 24 months in the tREACH trial in their:
(i) DAS, HAQ and X-ray progression
(ii) Prevalence of flares
(iii) Prevalence of attaining DAS44<1.6 at 2 consecutive time points
(iv) Prevalence of drug free remission at 24 months of follow-up
Methods Data were used from patients with recent-onset arthritis participating in a single-blinded clinical trial (treatment in the Rotterdam Early Arthritis CoHort (tREACH)) [1,2] in which induction therapy strategies were compared: (A) combination therapy (methotrexate (MTX) + sulfasalazine + hydroxychloroquine) with glucocorticoid (GCs) bridging or (B) MTX with bridging GCs. Disease activity scores (original DAS) were assessed every 3 months. Functional ability was assessed using the Health assessment questionnaire (HAQ). Actual medication use was obtained from medical charts and from patient diaries. DMARDs (synthetic (s) and/or biologic (b)) were tapered stepwise by protocol if DAS was <1.6 at 2 consecutive visits. For this analysis, a flare was defined as an increase in s/bDMARD use after initiation of tapering. Data were analysed using simple descriptive statistical techniques.
Results 281 rheumatoid arthritis patients (68% female; mean DAS 3.4, median HAQ 1.00) were initially randomized. After two years the difference in HAQ between group A and B was significantly different, irrespective of the DAS. Radiographic progression was minimal and similar for both groups, irrespective of tapering.
Data on DMARD use at 2 years were available from 248 patients (88%). Over time 139 of 281 (49%) patients (group A: 93 (51%), group B: 46 (47%)) attained DAS<1.6 at 2 consecutive time points. tapering of DMARDs was initiated at a median 9 months since start treatment. DMARD tapering was in 89% a sDMARD and 11% a bDMARD. At 24 months 19 patients (20%; group A) versus 12 patients (26%; group B) were in drug free remission, while 31 patients (17%; group A) versus 16 patients (16%; group B) had tapered their medication, but were still using DMARDs. At this time point DAS scores were similar for both groups, while HAQ scores were significantly higher in group B at both time points and also clinically different at 24 months.
Conclusions Half of patients in the tREACH trial was able to taper down medication after reaching sustained remission between 6 and 24 months of follow-up. Drug free remission was achieved by 11% of patients. Prevalence, time of initiation, radiographic progression and success of tapering were not different among the initial treatment groups. HAQ scores were significantly higher in the MTX monotherapy group compared to the triple DMARD therapy group.
Claessen et al. BMC Musculoskelet Disord 2009;10:71.
De Jong et al. Ann Rheum Dis. 2013 Jan;72(1):72-8.
Disclosure of Interest None declared