The British Journal of Rheumatology, Vol 37, 1157-1163, Copyright © 1998 by British Society for Rheumatology
AA Stenger, MA Van Leeuwen, PM Houtman, GA Bruyn, F Speerstra, BC Barendsen, E Velthuysen and MH van Rijswijk
OBJECTIVE: To evaluate the effect of early 'aggressive' drug treatment on
radiographic progression in patients with recent-onset rheumatoid arthritis
(RA), compared to conventional stepwise increasing intensity of treatment.
DESIGN: Prospective follow-up study with an experimental group and a
historical control group both divided into a high-risk subgroup and a
low-risk subgroup, based on prognostic factors. The effect of the
'aggressive' and the conventional treatment strategy was compared between
both high-risk groups; the low-risk groups, both treated according to the
conventional treatment strategy, were used to ensure internal consistency
between the experimental and the historical groups. PATIENTS: A total of
228 consecutive patients with recent-onset RA (complaints < 1 yr at
study entry). METHODS: The 'aggressive' drug treatment consisted of
institution of relatively fast-acting disease- modifying anti-rheumatic
drugs (DMARDs) (sulphasalazine, methotrexate) immediately after diagnosis,
and rapid adjustment of dosage and/or drug in the case of insufficient
response as measured by a change in C- reactive protein (CRP) level.
Radiographic damage was assessed according to a modified version of Sharp's
method and cumulative disease activity expressed as CRP-area under the
curve (CRP-AUC). The occurrence of side-effects was also evaluated.
RESULTS: After 2 yr of follow-up, comparison of the two high-risk subgroups
showed the radiographic progression in the 'aggressively' treated subgroup
to be significantly lower than that in the control group [Sharp score:
median (range) 26 (0-100) vs 35 (1-188); P = 0.03]. Cumulative CRP values
were also significantly lower than in the control high-risk subgroup [CRP-
AUC: median (range) 1963 (212-8515) vs 3025 (46-15 632) mg.week/1; P =
0.002). This was achieved without an increase in the occurrence of side-
effects. There was no difference between the two low-risk subgroups with
regard to entry characteristics, CRP-AUC values or radiological
progression, indicating comparability between the two groups. CONCLUSION:
Early 'aggressive' drug treatment, using sulphasalazine and/or
methotrexate, aimed at reduction of the CRP level, significantly reduces
the (rate of) radiographic progression in RA.
ORIGINAL PAPERS
Early effective suppression of inflammation in rheumatoid arthritis reduces radiographic progression
Department of Rheumatology, University Hospital Groningen, The Netherlands.
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