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We have been interested in the publication by Möttönen and colleagues concerning the outcome of patients with early rheumatoid arthritis (RA) who have been treated actively by disease suppressing drugs using a “sawtooth” strategy1 ,2 and have assessed the outcomes in our patients with early RA who have been treated using a similar strategy. Our study is prospective for five years and started in 1996. Up to now 50 patients have been recruited and followed up for two years. All patients fulfilled the American Rheumatism Association criteria for RA. Patients were treated actively with conventional doses of standard disease suppressing drugs. Disease activity was recorded using the disease activity score (DAS) (this included erythrocyte sedimentation rate, tender joint score, swollen joint score, and a global assessment score (VAS).
At two years 14 patients were in remission, nine patients showed partial improvement but were not in remission, 21 subjects have not shown an over all clinical improvement. (In 13 of these subjects the disease suppressing drugs have been stopped because of side effects, and in eight subjects the drug regimen has been tolerated but has not been effective so far). There were five drop outs and one non-drug related death. There were no significant clinical differences in the baseline measurements of disease severity or activity between those patients who subsequently developed remission with drug treatment and those who did not improve.
In conclusion, the most common cause for failing to respond to a regimen of treatment of early RA patients within two years is lack of tolerance to the disease suppressing drug regimen. The 28% remission rate noted in our patients at two years is very similar to the 27% noted by Möttönen and colleagues after two year of treatment suggesting that this figure could be used as a standard for those auditing the outcome of the management of early RA by different rheumatology centres.
We wish to thank Dr Teir and colleagues for the comments and their data concerning the outcome of patients with early rheumatoid arthritis (RA). We all agree now that the treatment of RA should aim at clinical remission. The frequency of the patients with achieved remission at two years after the institution of slow acting anti-rheumatic drugs (SAARDS) was quite similar in their cohort compared with our results (28% v 27%). However, it is notable that the figures concern patients treated actively with SAARDs in their early phase of disease. Therefore, in our opinion it is of crucial importance to describe accurately the treatment stragegy used in studies investigating the outcome and predictive factors of RA. Despite the observed seemingly high remission rates it is clear that the results obtained with these treatment modalities do not satisfy all the RA patients, especially those with most severe disease and we have to develop more effective strategies to treat RA patients.