Rheumatology Advance Access published online on November 26, 2007
Rheumatology, doi:10.1093/rheumatology/kem288
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Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early rheumatoid arthritis
Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
Correspondence to:
P. Verschueren, Department of Rheumatology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. E-mail: patrick.verschueren{at}uz.kuleuven.ac.be
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Abstract |
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Objective. To study prospectively the daily practice effectiveness of a step-down early rheumatoid arthritis (RA) treatment strategy.
Methods. Patients with severe RA and no contra-indications were proposed step-down therapy, the others step-up. Step-down patients received a modified combination therapy in early RA (COBRA) regimen: sulphasalazine (SPS), 2 g daily, and methotrexate (MTX), 15 mg weekly, combined with step-down oral prednisolone (start 60 mg daily, fast tapering to 7.5 mg over 6 weeks, discontinuation from week 28). At week 40, patients were randomized to maintenance therapy with either SPS or MTX if disease activity score-28 (DAS28) was acceptably low. The step-up group started disease-modifying anti-rheumatic drug (DMARD) monotherapy. In both groups, treatment was adjusted at follow-up, based on DAS28. DAS28, functionality Health Assessment Questionnaire (HAQ), adverse events, DMARD changes and steroid use were registered 4-monthly for 2 yrs.
Results. Ninteen patients received step-down and 52 step-up treatment. More patients completed the first year without unplanned DMARD changes and without dosage adjustment and fewer had DMARD changes due to side effects or inefficacy in the step-down group compared with step-up, whereas the number of adverse events was comparable. MTX proved to be the most effective maintenance therapy after step-down. The DAS response, proportion of patients in remission, HAQ response and proportion of patients without disability at 4 months was higher in the step-down group.
Conclusions. In daily practice, a step-down treatment strategy for early RA is more effective than a step-up approach.
KEY WORDS: Early rheumatoid arthritis, Treatment strategy, Remission induction, Step-down therapy, COBRA, Steroids
Submitted 23 June 2007;
revised version accepted 13 September 2007.
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