Update in Rheumatology

Rheumatoid Arthritis

Initial Combination Therapy Limited Damage and Resulted in Functional Improvement in Early Rheumatoid Arthritis

The main goals of treatment for rheumatoid arthritis are reduction of symptoms and signs of disease activity and prevention of long-term structural damage and functional decline. Effective therapies for rheumatoid arthritis include glucocorticoids, synthetic disease-modifying antirheumatic drugs like methotrexate and sulfasalazine, and inhibitors of tumor necrosis factor (TNF). It is known that initiation of treatment early in the course of the disease results in better long-term functional outcomes. However, the optimal initial choice, sequence, and combination of drugs are not known.

The investigators of this multicenter trial studied 508 Dutch patients with early, active rheumatoid arthritis. The median symptom duration was 23 weeks (interquartile range, 14 to 53 weeks), and the median time from diagnosis to enrollment was 2 weeks (interquartile range, 1 to 5 weeks). Patients were randomly assigned to receive sequential monotherapy (group 1), step-up combination therapy (group 2), initial combination therapy with tapered high-dose prednisone (group 3), or initial combination therapy with infliximab (group 4) (see details in Appendix). Investigators assessed patients' Disease Activity Score in 44 joints (DAS₄₄) every 3 months for a year. The DAS₄₄ is an index measure of disease activity that is based on the number of painful and the number of swollen joints, C-reactive protein or erythrocyte sedimentation rate, and patient's global assessment of disease activity status; the higher the measure, the worse the disease activity. If at a 3-month evaluation interval the patient's DAS₄₄ was 2.4 or less, representing suppressed disease activity and a strong therapeutic response, the patient continued the …