Rheumatology Vol. 44 No. 1 © British Society for Rheumatology 2005; all rights reserved
LETTER TO THE EDITOR |
How aggressive should initial therapy for rheumatoid arthritis be? The Finnish experience
Rheumatism Foundation Hospital, Heinola, 1 Jyväskylä Central Hospital, Jyväskylä, 2 Tampere University Central Hospital, Tampere, 3 Helsinki University Central Hospital, Helsinki, 4 Kuopio University Central Hospital, Kuopio, 5 Satakunta Central Hospital, Rauma, 6 Turku University Central Hospital, Turku and 7 Lappeenranta Central Hospital, Lappeenranta, Finland
Correspondence to: K. Kaarela. E-mail: kalevi.kaarela{at}reuma.fi
SIR, We read with interest the report of Matteson et al. [1] concerning 2-yr results of hydroxychloroquine (HCQ) treatment in 111 patients with early rheumatoid arthritis (RA). After 2 yr of follow-up, inflammatory activity decreased statistically significantly, but the percentage of patients with erosions increased from 26% to 59%. At 2 yr the mean number of swollen joints was nine, and 38 patients (40% of 94 who completed 2 yr) did not apparently have an ACR50 response. Despite these findings, the authors suggest that treatment with HCQ is ‘greatly beneficial in patients with early RA’.
A Finnish cohort from Heinola was one of the first prospective cohorts of patients with recent-onset (<6 months) RA. One hundred and three RF-positive patients were enrolled in this cohort in 1973–1975. At the time of diagnosis, 31% of patients began HCQ, 51% gold sodium thiomalate, 5% a combination of these, and 2% penicillamine; 85% were taking these drugs at the 1-yr visit and 76% at the 3-yr visit [2]. However, these treatments did not prevent severe joint damage or amyloidosis in most patients over the subsequent 20 yr [2–4]. In fact, HCQ has never been shown to prevent erosions in RA [5].
In the Finnish Rheumatoid Arthritis Combination Therapy trial (FIN-RACo) study, 195 patients with early RA were randomized to receive a combination of methotrexate (MTX), sulphasalazine (SSZ), HCQ and prednisolone vs SSZ only (with or without prednisolone), which could be switched to MTX or to another single anti-rheumatic drug [6]. At the 2-yr visit, 75% of patients who received combinations and 58% of patients who received a single DMARD therapy had ACR50 responses. Furthermore, remission was observed in 37% and 18% respectively. The importance of early remission was emphasized with the observation that all patients who met remission criteria during the first 6 months continued working for 5 yr, in contrast to work disability in 22% of patients who met ACR20 or ACR50 responses [7]. Furthermore, 54% of patients who improved less than ACR20 became work-disabled over 5 yr, similar to higher rates of work disability in the past.
Long-term follow-up will reveal whether the Mayo clinic study [1] is one of those described by Verna Wright: ‘Clinicians may all too easily spend years writing ‘doing well’ in the notes of a patient who has become progressively more crippled before their eyes’ [8].
The authors have declared no conflicts of interest.
References
- Matteson EL, Weyand CM, Fulbright JW, Christianson TJH, McClelland RL, Goronzy JJ. How aggressive should initial therapy for rheumatoid arthritis be? Factors associated with response to ‘non-aggressive’ DMARD treatment and perspective from a 2-yr open label trial. Rheumatology 2004;43:619–25.
[Abstract/Free Full Text] - Jäntti JK, Kaarela K, Belt EA, Kautiainen HJ. Incidence of severe outcome in rheumatoid arthritis during 20 years. J Rheumatol 2002;29:688–92.[Medline]
- Kaarela K, Kautiainen H. Continuous progression of radiological destruction in seropositive rheumatoid arthritis. J Rheumatol 1997;24:1285–7.[Web of Science][Medline]
- Sokka T. Early rheumatoid arthritis in Finland. Clin Exp Rheumatol 2003;21:S133–7.[Medline]
- Pincus T, Ferraccioli G, Sokka T et al. Evidence from clinical trials and long-term observational studies that disease-modifying anti-rheumatic drugs slow radiographic progression in rheumatoid arthritis: updating a 1983 review. Rheumatology 2002;41:1346–56.
[Abstract/Free Full Text] - Möttönen T, Hannonen P, Leirisalo-Repo M et al. Comparison of combination therapy with single-drug therapy in early rheumatoid arthritis: a randomised trial. FIN-RACo trial group. Lancet 1999;353:1568–73.[CrossRef][Web of Science][Medline]
- Puolakka K, Kautiainen H, Möttönen T, Hannonen P, Leirisalo-Repo M. Early control of disease activity maintains working capacity in early rheumatoid arthritis. Ann Rheum Dis 2004;63(Suppl. 1):56.
- Smith T. Questions on clinical trials. [Editorial]. Br Med J 1983;287:569.
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