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Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.
SUMMARIES FOR PATIENTS
What Is the Best Treatment Plan for Early Rheumatoid Arthritis?
20 March 2007 | Volume 146 Issue 6 | Page I-63
Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians.
The summary below is from the full report titled "Comparison of Treatment Strategies in Early Rheumatoid Arthritis. A Randomized Trial." It is in the 20 March 2007 issue of Annals of Internal Medicine (volume 146, pages 406-415). The authors are Y.P.M. Goekoop-Ruiterman, J.K. de Vries-Bouwstra, C.F. Allaart, D. van Zeben, P.J.S.M. Kerstens, J.M.W. Hazes, A.H. Zwinderman, A.J. Peeters, J.M. de Jonge-Bok, C. Mallée, W.M. de Beus, P.B.J. de Sonnaville, J.A.P.M. Ewals, F.C. Breedveld, and B.A.C. Dijkmans.
What is the problem and what is known about it so far?
Rheumatoid arthritis causes inflammation of the joints and often produces pain, deformity, and disability. The cause of the disease is unknown, but doctors know that the disease produces inflammation of the joint surfaces where the cartilage-covered ends of the bones rub against each another as the joint bends. Prolonged inflammation damages the joint and produces permanent changes in its structure. Doctors have used many medications to decrease joint inflammation and have been successful in managing the disease. Although some of that success has been achieved by using progressively more powerful disease-modifying antirheumatic drugs and medications that control inflammation, success also seems to be due in part to the way that doctors use combinations of these medications. To determine the best ways of treating rheumatoid arthritis early in the course of the disease, researchers began a study (known as the BeSt study) of patients who were treated with 1 of 4 plans. Group 1 received a single drug that was changed to another powerful drug every 3 months until the disease was controlled. Group 2 also started therapy with a single drug that was progressively stepped-up to combination therapy until control was achieved. Group 3 received combination therapy and high-dose prednisone until control was achieved. Group 4 received combination therapy and a new drug (infliximab) that blocks the body's ability to develop inflammation. In all groups, therapy was adjusted every 3 months until there was adequate disease control. Medication doses were reduced in all groups once the disease was controlled. Results during the first year showed that although all groups improved, groups 3 and 4 had more rapid control of the disease and had less damage to the joints than did groups 1 and 2.
Why did the researchers do this particular study?
To find out whether improvement could be maintained during the second year of treatment and what medication adjustments needed to be made for each group.
Who was studied?
508 patients who participated in the first year of the BeSt study.
How was the study done?
Patients were evaluated every 3 months by using a standardized scoring system known as the disease activity score. Evaluation of disease activity was done by a nurse who did not know the patient's treatment group. Changes in medication were made by doctors on the basis of the disease activity score and the group to which the patient was assigned.
What did the researchers find?
Improvement was maintained in all groups during the second year. By the end of the study, about one third of patients in groups 1, 2, and 3 and about half of the patients in group 4 had reached disease control with their first medication and needed only 1 drug. Eventually, all groups had clinical improvement.
What were the limitations of the study?
The patients and the physicians knew which treatment the patients were receiving.
What are the implications of the study?
Modern drug therapy can effectively control rheumatoid arthritis. Combination therapy produces more rapid disease control and probably limits joint damage more effectively than does therapy with a single drug.
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