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The therapeutic window of opportunity in rheumatoid arthritis: does it ever close?
  1. Karim Raza1,2,
  2. Andrew Filer1,3
  1. 1School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
  2. 2Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
  3. 3Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  1. Correspondence to Professor Karim Raza, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; k.raza{at}

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It is widely accepted in the rheumatology community that a ‘therapeutic window of opportunity’ exists for patients with rheumatoid arthritis (RA), that the disease is much more amenable to treatment within this window, and that treatment within the window can reset the disease's long-term trajectory in a way that treatment outside of it cannot. This concept is supported by data from studies which show that patients treated ‘early’, for example, within 3 months of the onset of symptoms, have favourable outcomes compared with patients treated later after symptom onset,1–4 and that aggressive therapy administered within an ‘early’ window can slow the rate of long-term structural damage.5 However, such data are equally consistent with a situation in which there is no point at which the ‘window’ closes but that earlier treatment is better than later treatment across the symptom duration spectrum. Understanding whether there is truly a time-limited window of opportunity in early RA is of critical importance. If such a window exists, then every effort must be made to see and treat patients before it closes and the research agenda needs to focus on the reasons for enhanced responsiveness within it.

Data from patients with RA from two large clinical cohorts have been analysed by van Nies et al to address the relationship between symptom duration at initial rheumatology assessment (a surrogate for the time from symptom onset to disease modifying anti-rheumatic drug (DMARD) commencement) and favourable outcomes, namely (1) DMARD-free sustained remission; (2) sustained remission irrespective of DMARD use and (3) low rates of radiological progression.6 Their key finding is that the relationships between symptom duration and favourable outcomes are not linear and that, for all outcomes, a point is reached after which the benefit gained by reducing time to treatment is lessened. Specifically for the authors’ …

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