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Optimal use of methotrexate: the advantages of tight control
  1. J W J Bijlsma1,
  2. M E Weinblatt2
  1. 1
    Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, the Netherlands
  2. 2
    Department of Rheumatology and Immunology, Brigham & Women’s Hospital, Boston, MA, USA
  1. Professor J W J Bijlsma, UMC Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands; j.w.j.bijlsma{at}umcutrecht.nl

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The CAMERA study shows that using methotrexate in a tight control setting might lead to considerable improvement in disease activity in early rheumatoid arthritisSee linked article p 1443

The outlook for patients who are in 2007 newly diagnosed with rheumatoid arthritis has improved dramatically.1 Important elements in this improvement are: (1) the concept of a “window of opportunity”: treat early and treat effectively;2 (2) early use of disease modifying anti-rheumatic drugs (DMARDs);3 (3) combination treatment, including glucocorticoids;4 5 (4) the use of biologicals;6 and (5) optimising therapy to the individual patient.

The CAMERA study reported in this issue by the Utrecht group See pages 1443 deals with this last item: optimising therapy to the individual patient.7 In this randomised controlled trial the drug treatment given to patients with early rheumatoid arthritis was the same in both groups, but the frequency and tightness of control were different. This report has some important messages that merit further comment:

1. The goal of tight control is feasible with the anchor drug methotrexate in a much larger proportion of patients than previously thought.

2. Using the same drug, but seeing the patient more often, and thus being able to adjust that specific drug more often, is much more efficacious then seeing the patient less frequently.

3. In a busy practice, tight control, aided by a computer-assisted protocol, is feasible.

TIGHT CONTROL

There is, as yet, no definition of “tight control” in rheumatoid arthritis. Elements of tight control are:

  • seeing the patient frequently, to enable frequent adjustments to the therapy;

  • improvement is not enough: the aim is low disease activity, or preferably even remission;

  • being as objective as possible in the judgment of disease activity; not the doctor’s or patient’s …

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