Objectives: To compare the occurrence of drug-free remission, functional ability and radiological damage after 4 years of response-driven treatment according to 4 different treatment strategies for rheumatoid arthritis (RA).
Methods: Patients with recent onset, active RA (n=508) were randomized to 4 different treatment strategies: (1) sequential monotherapy; (2) step-up combination therapy; (3) initial combination therapy with prednisone; and (4) initial combination therapy with infliximab. Treatment was adjusted based on three-monthly disease activity score (DAS) assessments, aiming at a DAS ≤2.4. From the third year, patients with a sustained DAS <1.6 discontinued treatment.
Results: In total, 43% of patients were in remission (DAS <1.6) at 4 years, and 13% were in drug-free remission: 14, 12, 8 and 18% of patients in groups 1-4, respectively. Absence of anti-cyclic citrullinated peptide antibodies, male gender and short symptom duration were independently associated with drug-free remission. Functional ability and remission were maintained in all 4 groups with the continuation of DAS-driven treatment, without significant differences between the groups. Significant progression of joint damage was observed in 38% and 31% of patients in groups 3 and 4 versus 51% and 54% of patients in groups 1 and 2 (P<0.05, group 4 versus groups 1 and 2, group 3 versus group 2).
Conclusions: In patients with recent onset active RA, drug-free remission was achieved in up to 18% of patients. DAS-driven treatment maintained clinical and functional improvement, independent of the treatment strategy. Joint damage progression remained significantly lower after initial combination therapy compared with initial monotherapy.