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Optimising the strategy of care in early rheumatoid arthritis

https://doi.org/10.1016/j.berh.2009.11.009Get rights and content

In rheumatoid arthritis (RA), early use of disease-modifying anti-rheumatic drugs (DMARDs), intensive follow-up and ‘treating to target’ to achieve low disease activity produce significant improvements in measures of disease activity, functional impairment and retard erosive radiographic progression. Step-up, parallel and step-down regimens are all significantly more effective than sequential monotherapy; although the most effective regimen has not been established. Minimising the period of exposure to synovitis, by including a rapidly acting agent (e.g., corticosteroids or tumour necrosis factor α (TNFα) inhibitor), may slow radiographic progression further. Biologic therapies, especially TNFα inhibitors, are effective in early RA; however, their exact role is unclear. Current measures may overestimate the number of patients in clinical remission; therefore, musculoskeletal ultrasound and/or novel biomarkers may also have a role. Pre-clinical immunological markers could possibly be used to trigger pre-emptive treatment in asymptomatic, ‘at risk’ individuals. Potential treatment developments include combining biologic agents or targeting alternative immunological pathways.

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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