Objectives: To compare the clinical and radiological efficacy of initial versus delayed treatment with methotrexate (MTX) and infliximab (IFX) in patients with recent onset rheumatoid arthritis (RA).
Methods: In a post-hoc analysis of the BeSt study, 117 patients who started initial MTX+IFX were compared with 67 patients who started MTX+IFX treatment after failing (disease activity score [DAS] >2.4; median delay to IFX: 13 months) on ≥3 traditional DMARDs. If the DAS remained >2.4, the protocol dictated IFX dose increases to 6, 7.5, and 10mg/kg. In case of a DAS ≤2.4 for ≥6 months, IFX was tapered and finally stopped. We aimed to correct for allocation bias using propensity scores. Functional ability was measured by the Health Assessment Questionnaire (HAQ), radiological progression by Sharp/van der Heijde scoring (SHS).
Results: Baseline differences between the initial and delayed groups were no longer significant after propensity score adjustment. Three years after baseline, patients treated with initial MTX+IFX experienced more improvement in HAQ over time, and were less likely to have SHS progression than patients treated with delayed MTX+IFX (P=0.034). Two years after IFX initiation, more patients in the initial group compared with the delayed group could discontinue IFX after a good response (56% versus 29%, P=0.008).
Conclusions: The results of this post-hoc analysis suggest that using MTX+IFX as initial treatment for recent onset RA patients is more effective than reserving MTX+IFX for patients who failed on traditional DMARDs, with more HAQ improvement over time, more IFX discontinuation and less progression of joint damage.