1Optimising the strategy of care in early rheumatoid arthritis
Section snippets
Core treatment principles
Many cases of early RA run an apparently indolent course though spontaneous remission is relatively rare [5]. Therefore, early referral for specialist rheumatological opinion and consideration of DMARD therapy is essential whenever RA is suspected. Early DMARD therapy is consistently associated with lower disease activity measures; a greater likelihood of achieving clinical remission [6], reduced radiographic progression rates [7], lower levels of long-term functional and work disability [8]
Conventional DMARD therapy in early RA
The next issue to be addressed is how clinicians can best achieve their target of LDAS as quickly as possible, and with the least risk. In most parts of the world, initial treatment is restricted to conventional DMARD therapy and there are some important questions to be answered about the optimal strategy for these drugs.
Biologic DMARD therapy in early RA
Biologic DMARDs are routinely used in the management of established RA, but their role in early RA has not been fully established. In many health-care systems, their use is restricted to patients who have already failed one or more conventional DMARDs [44]. Given that they are more effective than conventional DMARDs, it would be logical to use them in early RA too. Moreover, since they are tailored to specifically neutralise individual components of the immune response, administration during a
Diagnosis
Three phases in the development of RA have been described: (1) genetic predisposition which, following exposure to environmental triggers, leads to (2) asymptomatic autoantibody production and eventually (3) clinical inflammatory arthritis [64]. Since the available window to treat early RA is narrow, identification and monitoring of asymptomatic individuals at risk of later disease could allow initiation of immunomodulatory therapy at the very onset of inflammatory joint disease, or even before
Competing interests
James Dale
Research Funding – Wyeth
Duncan Porter
Medical advisory boards – Wyeth, Schering, Abbott Laboratories, UCB, Bristol-Myers Squibb and Hofmann-La Roche
Speaker fees – Wyeth, Schering, Abbott Laboratories, Hofmann-La Roche
Consultancy fees – Abbott Laboratories, Bristol-Myers Squibb, Hofmann-La Roche
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