Article Text

Download PDFPDF
Clinical and radiological efficacy of initial vs delayed treatment with infliximab plus methotrexate in patients with early rheumatoid arthritis
  1. S M van der Kooij1,
  2. S le Cessie1,
  3. Y P M Goekoop-Ruiterman1,
  4. J K de Vries-Bouwstra2,
  5. D van Zeben3,
  6. P J S M Kerstens4,
  7. J M W Hazes5,
  8. D van Schaardenburg4,
  9. F C Breedveld1,
  10. B A C Dijkmans2,4,
  11. C F Allaart1
  1. 1
    Leiden University Medical Center, Leiden, The Netherlands
  2. 2
    VU Medical Center, Amsterdam, The Netherlands
  3. 3
    Sint Franciscus Hospital, Rotterdam, The Netherlands
  4. 4
    Jan van Breemen Institute, Amsterdam, The Netherlands
  5. 5
    Erasmus Medical Center, Rotterdam, The Netherlands
  1. S M van der Kooij, Department of Rheumatology C-01-R, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands; smvanderkooij{at}


Objectives: To compare the clinical and radiological efficacy of initial vs 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 (for Behandel Stratagieen, Dutch for treatment strategies), 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 10 mg/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. At 3 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). At 2 years after IFX initiation, more patients in the initial group compared with the delayed group could discontinue IFX after a good response (56% vs 29%, p = 0.008).

Conclusions: The results of this post hoc analysis suggest that using MTX+IFX as initial treatment for patients with recent onset RA 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.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding: The BeSt study was supported by the Dutch College of Health Insurances. Schering-Plough and Centocor provided additional funding.

  • Competing interests: CFA and FCB have received lecture fees from Schering-Plough; BAD has received funds for research and lecture fees from Schering-Plough. The authors were responsible for the study design, the collection, analysis and interpretation of all data, the writing of this article and the decision to publish.

  • Ethics approval: The medical ethics committees of all participating centres approved the study protocol and all patients gave written informed consent before inclusion.