Early Treatment Benefits Patients with Rheumatoid Arthritis

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Early Treatment Benefits Patients with Rheumatoid Arthritis

Newswise — Early, aggressive treatment may be most beneficial,

according to research presented this week at the American College of

Rheumatology Annual Scientific Meeting in San Diego, California.

The BeSt study is a multi-center, randomized controlled trial

designed to evaluate the effectiveness of four different treatment

strategies for patients with early, active rheumatoid arthritis who

had not yet received DMARD therapy. A total of 508 patients with

active rheumatoid arthritis whose symptoms were in place for two

years or less were randomized into one of four treatment groups:

sequential monotherapy (group one: 126 patients); step-up combination

therapy (group two: 121 patients); initial combination therapy with a

tapered high dose prednisone (group three: 133 patients); and initial

combination therapy with methotrexate and infliximab (group four: 128

patients). Patients were frequently seen and their disease activity

was assessed. If the target of low disease activity was not reached,

treatment was changed according to an algorithm specific for each of

the 4 groups. Researchers will present three sets of findings during

the ACR annual meeting based on the BeSt study.

In the first set of findings (presentation #1865), researchers

focused on the treatment strategy that should be pursued after

patients failed on methotrexate (generally the first line of

treatment for early rheumatoid arthritis). After six months of

treatment in one of the four treatment groups, 44% of patients in

groups one and two did not respond to methotrexate monotherapy.

Switching to another DMARD, or adding another DMARD for combination

therapy also did not yield acceptable percentages of patients

achieving acceptable DAS scores. However, researchers did find that

the majority of patients failing on multiple DMARDs still respond to

a combination therapy of methotrexate and a TNF inhibitor (infliximab).

In the second set of findings (presentation #1467), researchers set

out to determine if the rapid clinical improvement with initiation

combination therapy with either prednisone or infliximab were

reflected by patients’ self-assessed outcomes for pain, disease

activity (e.g., prevalence and severity of symptoms) and performance.

All patients completed the MACTAR questionnaire, an instrument used

to assess improvement in physical disability (functional outcome), as

well as scores for pain, overall health and disease activity (known

as VAS scores) every visit during the first year of follow-up.

Baseline characteristics were comparable for all groups at the

beginning of the study. Functional outcomes improved more rapidly in

groups three and four. After one year, differences among the four

groups were smaller, but patients in group four (methotrexate plus

TNF inhibitor) scored significantly better than patients in group

one. Patients’ scores for pain, overall health and disease activity

were significantly lower than baseline in all four groups after one

year. In all groups, treatment resulted in substantial improvement in

functional ability and self-assessed VAS scores; however, patients

initially treated with combination therapy showed more rapid

improvement than patients in the mono- or step-up therapy groups.

In the third set of findings (presentation #843), researchers set out

to identify patients with osteoporosis and evaluate possible risk

factors for osteoporosis in people with early, active rheumatoid

arthritis. Baseline bone mineral density measurements of the lumbar

spine and total hip were performed by DXA in 342 patients (240 women

and 102 men with a mean age of 54.6 years). Radiological damage of

the hands and feet was also assessed. In this group, the clinical,

demographic and radiological characteristics of patients that had

osteoporosis and those that did not were compared and assessed.

Osteoporosis was found more often in patients with a positive

rheumatoid factor, an older age, in postmenopausal women and in those

with low body mass index – the last three classic risk factors.

However, researchers did note that the duration of rheumatoid

arthritis or its activity did not correlate with osteoporosis.

" With various outcome-targeted treatment strategies using tight

disease control, more than 40% of patients with early rheumatoid

arthritis can be brought into remission, and the large majority in a

state of low disease activity without progressive joint destruction,”

said Ferdinand C. Breedveld, MD, and lead investigator in the BeSt

study. “Of the four treatment strategies compared (sequential

monotherapy, step up, initial combination therapy with

corticosteroids and initial therapy with TNF antagonists), the last

two reach an earlier therapeutic success with respect to DAS, HAQ and

remission as well as a more complete inhibition of radiographic

progression compared to the first two. Given the non-significant

outcome of the four groups with respect to disease activity levels

after two years, the conclusion at this moment is that all strategies

are successful as long as the treatment follows the decision scheme

of tight disease control, with every-three-months changes of therapy

if the goal is not reached. Also in strategies one, two and three,

TNF antagonists are needed at the 10 to 28% level within two years to

reach this goal.”

The American College of Rheumatology is the professional organization

for rheumatologists and health professionals who share a dedication

to healing, preventing disability and curing arthritis and related

rheumatic and musculoskeletal diseases. For more information on the

ACR’s annual meeting, see http://www.rheumatology.org/annual.