Early combination disease-modifying antirheumatic drug therapy and tight disease control improve long-term radiologic outcome in patients with early rheumatoid arthritis: the 11-year results of the Finnish Rheumatoid Arthritis Combination Therapy trial

Abstract

IntroductionEarly treatment of rheumatoid arthritis (RA) has been shown to retard the development of joint damage for a period of up to 5 years. The aim of this study was to evaluate the radiologic progression beyond that time in patients with early RA initially treated with a combination of three disease-modifying antirheumatic drugs (DMARDs) or a single DMARD.MethodsA cohort of 199 patients with early active RA were initially randomized to receive treatment with a combination of methotrexate, sulfasalazine, and hydroxychloroquine with prednisolone (FIN-RACo), or treatment with a single DMARD (initially, sulfasalazine) with or without prednisolone (SINGLE). After 2 years, the drug-treatment strategy became unrestricted, but still targeted remission. The radiographs of hands and feet were analyzed by using the Larsen score at baseline, 2, 5, and 11 years, and the radiographs of large joints, at 11 years.ResultsSixty-five patients in the FIN-RACo and 65 in the SINGLE group had radiographs of hands and feet available at baseline and at 11 years. The mean change from baseline to 11 years in Larsen score was 17 (95% CI, 12 to 26) in the FIN-RACo group and 27 (95% CI, 22 to 33) in the SINGLE group (P = 0.037). In total, 87% (95% CI, 74 to 94) and 72% (95% CI, 58 to 84) of the patients in the FIN-RACo and the SINGLE treatment arms, respectively, had no erosive changes in large joints at 11 years.ConclusionsTargeting to remission with tight clinical controls results in low radiologic progression in most RA patients. Patients treated initially with a combination of DMARDs have less long-term radiologic damage than do those treated initially with DMARD monotherapy.Trial registrationCurrent Controlled Trials ISRCTN18445519.

Response to traditional disease-modifying anti-rheumatic drugs in indigent South Africans with early rheumatoid arthritis

“…The concept that response to DMARDs is evident within 3-6 months of initiating therapy has been described previously 24 and emphasizes the importance of escalating DMARD therapy early and rapidly in patients who fail to achieve at least LDA. These findings call for a more aggressive approach to the use traditional DMARDs, and an intense "treat-to-target" strategy such as used in the TICORA and FIN-RACo studies, needs to be explored in this setting 25,26 .…”

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“…Intensive modern treatment strategies, however, decrease the prevalence of these "typical" RA features, which are frequently the consequence of long periods of uncontrolled disease activity that we aim to avoid in the modern era 5,11 .…”

“…As a result, there was an absence of evidence regarding the efficacy of new treatments in this group of patients, who may have had the potential to benefit the most 4,5 . Thus, 1 aim of the 2010 criteria was to identify those patients with early RA with the key purpose of rapid disease-modifying antirheumatic drug (DMARD) initiation.…”

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“…Patients in the FIN-RACo (Finnish Rheumatoid Arthritis Combination Therapy) study who did not achieve remission by 1 year experienced a substantially higher rate of progression of joint erosions over the ensuing decade than did patients who did achieve remission. 80 Combination regimens are markedly more likely than monotherapy regimens to induce remission. 81 The window of 6 to 12 months is chosen because in patients in whom biologic therapy was initiated at 3 months, up to 6 months may justifiably be required before the treatment response can be definitively assessed.…”