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Short Term, Beneficial Effects of Early DMARD Treatment in Rheumatoid Arthritis

Immediate disease-modifying antirheumatic drugs treatment in patients with early rheumatoid arthritis shows better short-term results than delayed DMARD treatment, according to a recent Dutch review.

Traditional management of early rheumatoid arthritis consisted of a 'pyramid' approach that began with nonsteroidal anti-inflammatory drugs (NSAIDs) that were replaced by DMARDs if ineffective.

Recent studies have suggested earlier introduction of DMARDs confers a clinical advantage at 1-year follow up over delayed treatment. However, the long term effects have yet to be studied.

Suzan M. M. Verstappen, MSc, and colleagues at the University Medical Center Utrecht, the Netherlands and Dutch colleagues evaluated the long term effects of early DMARD treatment.

The study included 238 patients with early RA disease who were randomised to receive either 1) the pyramid approach (56 patients); or 2) DMARDs from onset (182 patients). DMARD regimens consisted of intramuscular gold (aurothioglucose, 50 mg/week; second choice D-penicillamine, 500 to 750 mg/day), hydroxychloroquine (400 mg/day; second choice auranofin, 6 to 9 mg/day), or oral methotrexate (7.5 to 15 mg/week; second choice sulfasalazine 2,000 to 3,000 mg/day), depending upon patient response after first year. Follow-up examinations were conducted up to 5 years after start of study.

All patients within the pyramid group received NSAIDs for at least 1 year; however, at final evaluation, only 6 patients were continuing NSAID treatment. These patients had lower joint scores and less radiographic damage at baseline than those patients who switched to DMARD treatment.

While patients receiving early DMARD treatment showed favourable results at early follow-up evaluations as compared to those on the pyramid approach, the clinical advantage was not apparent at later evaluations. Beneficial effects over the pyramid approach were observed in erythrocyte sedimentation rate (ESR), Thompson joint score, morning stiffness, functional disability, general well-being, pain, and grip strength early in the DMARD treatment period.

Furthermore, the percentage of patients showing clinically relevant individual improvement was significantly higher in the early DMARD group than in the pyramid group starting at 3 months (48% versus 25%) and up to 21 months (70% versus 55%). This effect, however, also did not extend to later follow-up examinations.

The early DMARD treatment group also had a significantly shorter lag time to first complete response than the pyramid group, 12 months versus 20 months, respectively.

The authors conclude that "clinical results in favour of the early DMARD group, as observed after the first year, were not as evident after 5 years." They therefore recommend that "a more aggressive treatment approach in early RA is required, and that treatment should be continued for a prolonged period of time, in order to maintain the advantages obtained in the first year."
Arthritis Rheum 2003;48:7:1797-1807. "Five-year followup of rheumatoid arthritis patients after early treatment with disease-modifying antirheumatic drugs versus treatment according to the pyramid approach in the first year"

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