Delayed progression of joint damage with aggressive initial treatment in early rheumatoid arthritis

This study evaluated the frequency of disease remission and the long-term progression of joint damage in patients with early rheumatoid arthritis initially treated with aggressive combination therapy compared to a single anti-rheumatic drug.

Rheumatoid arthritis (RA) is a life-long condition characterized by chronic inflammation of the joints which may severely interfere with activities of daily living. Treatment of RA therefore aims to achieve remission of disease symptoms, and delay the progression of joint damage. An abundance of evidence indicates that early intervention with

disease-modifying anti-rheumatic drugs (DMARDs) significantly improves disease outcomes. DMARD's refer to a collection of drugs, including methotrexate, sulfasalazine and hydroxychloroquine, which modify the behavior of the immune system and help reduce inflammation.

Usually a single DMARD (most commonly methotrexate) is initiated, and only if this regimen fails few drugs may be combined. However, recent studies have demonstrated that treatment of early RA with a combination of DMARD's is well tolerated and provides better response rates than treatment with a single agent. Furthermore, research indicates that response to initial treatment significantly improve long-term disease outcomes.

In this prospective study, 195 patients with early, clinically active, RA were randomly assigned to either standard monotherapy with a single DMARD (sulfasalazine) or aggressive initial therapy with a combination of three DMARD's, including methotrexate, sulfasalazine and hydroxychloroquine. Patients were treated for two years, following which they continued with their treatment of choice based on their physician's recommendation. The frequency of remissions and the extent of joint damage seen on imaging scans of the hands and feet were examined annually for up to 5 years following randomization.

At 2 years following treatments, 40% of the patients in the aggressive initial therapy group and 18% of patients in the monotherapy group had achieved remission of the disease. However, at 5 years only a non-significant difference was noted in the rate of remission, with 28% of the patients receiving aggressive therapy and 22% of patients in the monotherapy group achieving disease remission.

On the other hand, patients given aggressive therapy demonstrated significantly slower progression of joint damage at both 2, and 5 years following treatments.

The rate of serious adverse effect did not differ between treatment groups.

This study concluded that aggressive initial treatment of early RA with the combination of three DMARDs significantly slows the progression of joint damage.