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The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study
  1. Naomi B Klarenbeek1,
  2. Melek Güler-Yüksel1,
  3. Sjoerd M van der Kooij1,
  4. K Huub Han2,
  5. H Karel Ronday3,
  6. Pit J S M Kerstens4,
  7. Patrick E H Seys5,
  8. Tom W J Huizinga1,
  9. Ben A C Dijkmans4,6,
  10. Cornelia F Allaart1
  1. 1Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  2. 2Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
  3. 3Department of Rheumatology, Haga Hospital, The Hague, The Netherlands
  4. 4Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands
  5. 5Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands
  6. 6Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Dr N B Klarenbeek, Department of Rheumatology, C-01-R, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands; n.b.klarenbeek{at}


Objective To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up.

Methods 508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS <1.6 during ≥6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages.

Results After 5 years, 48% of patients were in clinical remission (DAS <1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2–5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response.

Conclusion Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.

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  • Funding The trial was sponsored with a government grant from the Dutch College of Health Insurance Companies with additional sponsoring by Centocor Inc. and Schering-Plough Ltd. The sponsors were not involved in the study design, data collection, data analysis or preparation of the manuscript.

  • Competing interests TWJH, BACD and CFA received speakers' fees from various pharmaceutical companies (less than US$5000 per year).

  • Patient consent Obtained.

  • Ethics approval Ethics approval was obtained at the medical ethical committees of all participating centres.

  • Provenance and peer review Not commissioned; externally peer reviewed.