Background Part of the cases with undifferentiated arthritis (UA), an inflammatory oligo-arthritis without definitive diagnosis, may be a first manifestation of rheumatoid arthritis (RA). As early treatment in RA results in better outcomes, starting treatment in the stage of UA may be even more beneficial.
Objectives We performed a systematic literature to assess the efficacy of various drug therapies in patients with UA.
Methods The systematic literature search was conducted using electronic databases Pubmed, EMBASE and MEDLINE and restricted to adults with undifferentiated or early arthritis (not fulfilling the ACR 1987 or ACR/EULAR 2010 criteria for RA). Search terms for UA were ‘undifferentiated’ or ‘early’ or ‘unclassified’ or ‘probable (inflammatory) arthritis’ or ‘oligo-’ or ‘polyarthritis’. Drug therapy consisted of disease modifying anti-rheumatic drugs (DMARDs), biological agents and oral, intra-muscular or intra-articular corticosteroids.
Results Eight randomized controlled trials (RCTs), two uncontrolled open-label trials and 7 cohort studies were included. Temporary treatment with methotrexate (MTX) was more effective in suppressing radiologic progression compared to placebo in an RCT with 30 months follow up (6 patients in the MTX versus 14 in the placebo group developed progression, p=0.046). Development of RA was postponed but not prevented by 1 year of MTX. A 6 months course of abatacept was shown to suppress radiological damage in a placebo controlled RCT with one year follow up (difference in total Genant-modified Sharp score of -1.10 (95%CI -2.05 to -0.15)). Percentages patients developing RA did not differ significantly between the abatacept and placebo group. A three week course of intramuscular glucocorticosteroid (GC) injections led to fewer patients needing DMARD treatment after 6 months compared to placebo (61% in the GC group versus 76% in the placebo group) but progression to RA over 1 year did not differ significantly between both groups. One study suggests that DMARD combination therapy (MTX+sulfasalazine+ hydroxychloroquine), at least after 4 months, is superior to MTX alone in suppressing disease activity in UA patients at high risk of developing persistent arthritis (difference in DAS (95%CI) 0.39 (0.67-0.11) in favor of the combination therapy group). One RCT trial shows no benefit for UA patients of tight control treatment over conventional care in terms of radiological and clinical outcomes and achieving remission. The open label uncontrolled trials and cohort studies suggested that early treatment may provide early suppression of inflammation. The long term benefit of early treatment in UA remains unclear.
Conclusions Trials and cohorts suggest that early treatment may suppress current symptoms and postpone progression to RA and radiological damage, but reports on long term results are scarce. Which treatment may provide the best results or may alter the disease course still has to be determined. More randomized clinical trials with longer follow up time are needed.
Disclosure of Interest None Declared
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