There is strong evidence from clinical trials that a ‘treat to target’ strategy is effective in reaching remission in rheumatoid arthritis (RA). However, the question is whether these results can be translated into daily clinical practice and clinical remission is a reachable target indeed.
Objective The study aims to investigate whether in early RA a treatment strategy aiming at Disease Activity Score (DAS) 28 <2.6 is more effective than ‘usual care’ treatment for reaching clinical remission after 1 year.
Methods Two early RA inception cohorts from two different regions including patients who fulfilled the American College of Rheumatology criteria for RA were compared. Patients in the tight-control cohort (n=126) were treated according to a DAS28-driven step-up treatment strategy starting with methotrexate, addition of sulphasalazine (SSZ) and exchange of SSZ by anti-tumour necrosis factor in case of failure. Patients in the usual-care cohort (n=126) were treated with methotrexate or SSZ, without DAS28-guided treatment decisions. The primary outcome was the percentage remission (DAS28<2.6) at 1 year. Time to first remission and change in DAS28 were secondary outcomes.
Results After 1 year, 55% of tight-control patients had a DAS28<2.6 versus 30% of usual care patients (OR 3.1, 95% CI 1.8 to 5.2). The median time to first remission was 25 weeks for tight control and more than 52 weeks for usual care (p<0.0001). The DAS28 decreased with −2.5 in tight control and −1.5 in usual care (p<0.0001).
Conclusion In early RA, a tight control treatment strategy aiming for remission leads to more rapid DAS28 remission and higher percentages of remission after 1 year than does a usual care treatment.
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Contributors J Fransen and HH Kuper contributed in the study concept. P van Riel and M van de Laar contributed in the cohort and intervention design. L Schipper, M Vermeer and J Fransen contributed in the analysis. LG Schipper, M Vermeer and J Fransen. M Hoekstra, C Haagsma, A den Broeder, M van de Laar and P van Riel reviewed the manuscript.
Funding The work of LG Schipper was supported by an implementation grant by Wyeth Pharmaceuticals, The Netherlands. The work of M Vermeer was funded by an unrestricted educational grant by Abbott, The Netherlands. The study sponsors had no influence on the study design, collection, analysis and interpretation of data, in the writing of the report and in the decision to submit the paper for publication.
Competing interests The co-authors cooperate in the Dutch Rheumatoid Arthritis Monitoring biological registry, for which funding has been received from the Dutch affiliations of Wyeth Pharmaceuticals, Abbott Pharmaceuticals, Schering-Plough Corporation, Roche pharmaceuticals, UCB Pharma and Bristol-Myers Squibb to enable data collection for the Dutch Rheumatoid Arthritis Monitoring registry.
Ethics approval Ethics approval was obtained from the Medisch Ethische Toetsingscommissie Arnhem Nijmegen and the Medisch Ethische Toetsingscommissie Twente.
Provenance and peer review Not commissioned; externally peer reviewed.