The BeSt Way to Treat Early Rheumatoid Arthritis?

Over the past few years, the outlook for patients who are newly diagnosed with rheumatoid arthritis (RA) has improved dramatically (1) because of several key advances, including early use of disease-modifying, antirheumatic drugs (DMARDs); the use of DMARDs in combination; use of biologicals, especially antitumor necrosis factor-α agents; and recognition of the critical role of inflammation in the vascular complications that lead directly to death. Patients who are diagnosed with RA today are much less likely to become disabled, require joint replacement (2), or die of premature atherosclerotic disease, which is associated with RA-related systemic inflammation.

Despite these advances, many questions remain about initial therapy for early RA. In this issue, Goekoop-Ruiterman and colleagues (3) shed light on 2 very important questions: Should patients with early RA receive combinations of DMARDs as initial therapy? Is it helpful for clinicians to set clear treatment goals? Many studies have shown that combination DMARD therapy is superior to monotherapy when treating groups of patients with RA (4–10). Conversely, trials have also shown that a substantial percentage of patients will do well on monotherapy (1, 9–12). Unfortunately, most important trials of the past decade are rigid, therapy A versus therapy B comparisons and do not allow clinicians to adjust therapy to meet treatment goals (4–15). These trials often give clear answers, but they don't mimic daily practice.

Goekoop-Ruiterman and coworkers (3) present the 2-year outcomes of an important clinical trial—the BeSt study (Dutch acronym for Behandel–Strategieen, “treatment strategies”)—which examines 4 substantially different treatment …