Background The effectiveness of treat to target (T2T) in RA is widely acccepted, but there is no consensus regarding the best initial treatment in early rheumatoid arthritis1. Therefore, it is important to evaluate the results of such strategies in real life cohorts2,3.
Objectives Compare the effectiveness of step-up methotrexate (MTX) monotherapy and combination of hydroxychloroquine (HCQ), methotrexate and intramuscular injection of triamcinolone 80–120mg as initial treatment in early RA.
Methods Historical cohorts of patients treated with MTX monotherapy (disease onset 2006–2011, N=297) and combination therapy (2012–2016, N=156) were compared. In both cohorts a b-DMARD was advised when no remission was reached within 6 months or in case of sustained activity thereafter. Baseline characteristics and disease activity (DAS28) measurements (N=4956, average 4.1/year) in the first 3 years of follow-up were available. The primary outcome measure was the proportion of patients having reached at least one DAS28 <2.6 (remission) during follow-up. Secondary outcomes were sustained remission over 36 months and time to first b-DMARD.
Results Three patients did not start MTX, and 11 and 2 patients in the step-up and combination cohorts respectively did not have complete follow-up (Table). Within 12 months, more patients on combination treatment reached remission (88,2% vs 72.2%). In the second year these changed to 86.5% and 82.0% respectively. Combination treatment resulted in a higher percentage of DAS measurements below 2.6 over 3 years, reflecting sustained remission (Figure). A b-DMARD was started within 24 months in 20.6% of patients on monotherapy versus 14.1% on combination treatment, with an equal mean time to first b-DMARD of 12 vs 11 months after start of initial treatment.
Conclusions Combination treatment results in more remissions in the first year of treatment. In the second and third year the remission percentage on monotherapy comes close to combination treatment, at the cost of a 6% higher proportion of patients stepping up to biologicals. Overall, the combination of MTX with HCQ and triamcinolone results in more sustained remissions.
Stoffer M, Schoels M, Smolen J et al. Evidence for treating rheumatoid arthritis to target: results from a systematic literature search update. Ann Rheum Dis 2016; 75:16–22.
de Jong P, Hazes J, Barendregt P et al. Induction therapy with a combination of DMARDs is better than methotrexate monotherapy: first results of the tREACH trial. Ann Rheum Dis 2013; 72:72–8.
Steunebrink L, Versteeg G, Vonkeman H et al. Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry. Art Res & Ther 2016: 10.1186/s13075–016–0962–9.
Disclosure of Interest None declared