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Early treatment of rheumatoid arthritis: rationale, evidence, and implications
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  1. L B A VAN DE PUTTE,
  2. A M VAN GESTEL,
  3. P L C M VAN RIEL
  1. Department of Rheumatology, University Hospital Nijmegen, PO Box 9101, 6500 HB Nijmegen, the Netherlands
  1. Professor van de Putte.

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In recent years the therapeutic attitude towards rheumatoid arthritis (RA) has changed considerably. Now, the disease is treated in an increasingly earlier phase and also more aggressively.1As is often the case in medicine, the process leading to this change in therapeutic attitude is not easy to unravel, as it might consist of a mixture of (seemingly) rational arguments and instinctive feelings, including dissatisfaction with current therapeutic modalities, new therapeutic options, changed insights into the pathogenesis, new hypotheses, etc.

In this article we will focus on the early treatment principle, being related to, but definitely distinct from the topic of more aggressive treatment of the disease, which will not primarily be dealt with here. We will briefly mention the rationale for treating patients with RA as early as possible, and thereafter review the current evidence available for this change in therapeutic attitude. Finally, we mention possible consequences of early treatment of RA, both for teaching and training as well as for the health care system.

Rationale for early treatment

A number of observations and arguments have led in the recent past to earlier (and more aggressive) treatment of RA. It has become clear that the way of treatment prevailing until recently, was insufficient to prevent ultimate disability and joint destruction.2Furthermore, RA, especially its more severe and systemic forms, is not only a disabling disease, but also associated with increased mortality.2 3

In the past years, it has become clear from a number of studies that in the “natural history” of RA, joint destruction occurs relatively early in the disease—that is, in the first years after onset.4 A hopeful finding of some years ago, was that in those patients that were apparently treated successfully (or had a spontaneous remission) progression of joint destruction had decreased or even stopped.5 As …

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