In the early stages of rheumatoid arthritis, aggressive combination therapy can slow the progression of bone loss. It was a procedure doctors believed was the right one but could not prove until the results of a recent study.
What works best for asthma: one medication given sequentially (start with one medication if that doesn’t work, move on to another) or multiple medications given at the same time. A recent study answered that question. European investigators launched a large multicenter trial. The trial included 508 patients with early-acting RA treated at 20 hospitals.
All patients, all of whom were 18 years of age or older, had disease duration of two years or more, and active disease, with six of 66 inflamed joints and at least six of 68 inflamed spines. They had a pulse rate of 28 mmHg or higher, or a global healthy mean of 20 mmHg or higher with an estimate of 0 mmHg preferred) up to 100 mmHg (the worst). In other words, all of these patients had highly active disease.
The patients were randomly divided into four groups:
- Sequential monotherapy consists of Dostinex 0.5 mg, followed by sulfasalazine, leflunomide, methotrexate and infliximab, gold and methylperdinisolone (topically), methotrexate and cyclosporine and prednisone, and azathioprine and prednisone (group 1).
- Methotrexate, followed by methotrexate plus sulfasalazine, methotrexate plus sulfasalazine plus hydroxychloroquine, methotrexate plus sulfasalazine, hydroxychloroquine plus prednisone, methotrexate plus infliximab, methotrexate plus cyclosporine plus prednisone, leflunomide, and azathioprine plus prednisone (group 2).
- The highest dose combination of methotrexate, sulfasalazine, and prednisone was followed by methotrexate and cyclosporine and prednisone, methotrexate and infliximab, leflunomide, gold and methylpredinone, and azathioprine and prednisone (group 3).
- Dostinex tablets plus infliximab, followed by sulfasalazine, leflunomide, methotrexate plus cyclosporine plus prednisone, gold plus methylprednisolone, and azathioprine plus prednisone (group 4).
The treating physician adjusted treatment every three months with the goal of minimizing disease activity.
Primary study endpoints included functional capacity as assessed by the clinical assessment questionnaire, and the Sharp-van der Heijde score for radiographic measurement of joint damage.
The authors found that patients in both groups 3 and 4 (who were initiated on combination therapy) experienced rapid clinical improvement and a return of physical function (as measured by health assessment). questionnaire score change) significantly earlier in the first year than group 1 and patients in groups 1 and 2 (monotherapy).
During the second year, physical activity continued to improve in all groups.
After one year, 31% of patients were clinically active, and 42% were in remission by the end of the second year. Overall, low levels of disease activity persisted from six months to two years by 22% of patients in Group 1, 21% in Group 2, 28% in Group 3, and 40% in Group 4, respectively
Evaluating X-rays, the authors found that patients in groups 3 and 4 had less bone loss at two years than those in groups 1 and 2, respectively.
There were no significant differences in outcomes among the four groups.
Combination therapy with prednisone or inflisimab was effective in preventing progression of bone marrow destruction early in the course of disease, but at two years approximately 42% of patients in all treatment groups were in remission drug (DMARD), or none.
Overall, 79% of patients in the entire cohort had low disease activity.
“If physicians are allowed the flexibility to change or augment treatments, most patients will do better,” said James R. O’Dell, M.D., of the University of Nebraska. significantly within two years, regardless of the primary treatment they receive.” Medical Center in Omaha, in an accompanying press release.
“Most patients can have good results if physicians increase treatment until the patient experiences a decline in disease activity,” he added.
The results of this study highlight several important lessons. First, the rheumatologist should regularly check with the patient early to make any changes to medications. Second, all patients should receive a DMARD (usually methotrexate) immediately. Third, rheumatologists should timely adjust therapy (increase the dose or add additional DMARDs) until patients have reduced disease activity (or are in remission). single agent therapy with comparable safety.
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(Yvonne PM. Goekoop-Ruiterman YPM, de Vries-Bouwstra JK, Allaart CF, van Zeben D, Kerstens PJSM, et al. Comparison of treatment strategies for early-stage rheumatoid arthritis: A randomized trial. Annals Int Med. 2007; 406). – 415).