9
Drug management of early rheumatoid arthritis – 2008

https://doi.org/10.1016/j.berh.2008.08.003Get rights and content

Modern therapy of rheumatoid arthritis (RA) is based on recognition of the severity of the natural history of disease, with early and aggressive treatment strategies. Methotrexate is the anchor drug, with addition of other disease-modifying anti-rheumatic drugs (DMARDs) in combinations, and biological targeted therapies. The approach emphasizes ‘tight control’, aiming for remission and low disease activity according to quantitative monitoring. In this chapter, we review selected randomized controlled studies for data concerning early versus delayed therapies. We present a historical perspective for the treatment of early RA using early RA cohorts from Finland as an example. Finally, we discuss principles of contemporary treatment of early RA in 2008.

Section snippets

A concept of early RA

The term ‘rheumatoid arthritis’ is used to describe a syndrome that may result in a destructive symmetrical polyarthritis and is often associated with the presence of rheumatoid factor [31]. Identification of RA in the early stages is both important and difficult. Criteria for RA have been developed since 1907 [32]. However, even the current set of criteria, the American Rheumatism Association (now the American College of Rheumatology, ACR) 1987 revised criteria [33], do not differentiate

Early versus delayed drug treatments in randomized controlled trials of early RA

The benefits of early versus delayed treatment have been documented in studies of intramuscular (IM) gold [41], auranofin [42], sulphasalazine (SSZ) [43], [44], and hydroxychloroquine (HCQ) [45]. Disease duration at the time of DMARD initiation was the primary predictor of the response to DMARD treatment in a meta-analysis [46]. One study concluded that very early treatment with MTX may postpone the development of RA [47].

The Finnish RA Combination Therapy Trial, termed the FIN-RACo study,

Historical perspective concerning the treatment of early RA

Benefits of early versus delayed drug treatments in RA were first recorded in an observational study by Luukkainen et al [54] which showed that patients treated with IM gold early in the course of RA had lower radiographic progression over 5 years than those treated with gold at later stages. These results have been confirmed in further observational studies of other DMARDs [55], [56], [57], *[58].

Several early RA cohorts have been established in Finland since the 1970s. Longitudinal

General principles of drug therapy for RA

The contemporary approach to patients with early arthritis is based on identification of patients with early RA, early use of available therapies in suspected cases to control inflammation as completely as possible, tight control according to quantitative monitoring in order to prevent long-term damage [73], and using methotrexate as the anchor drug *[73], [74].

Conclusion

Treatments for early RA should aim for remission as soon as possible to avoid severe side-effects of RA. Patients with early RA should be seen frequently and monitored tightly. MTX is the anchor drug, although therapies should be tailored individually for each patient.

The authors of this chapter represent a typical patient with early RA with respect to sex (female) and age (mean 50.1; SD 2.7). If we developed early active RA, we would begin MTX up to 25 mg and low-dose prednisolone (5 mg) (with

Acknowledgments

Theodore Pincus for helpful comments.

References (99)

  • T. Pincus et al.

    Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over nine years

    Arthritis Rheum

    (1984)
  • D.L. Scott et al.

    Progression of radiological changes in rheumatoid arthritis

    Ann Rheum Dis

    (1984)
  • E. Yelin et al.

    Work disability in rheumatoid arthritis: effects of disease, social, and work factors

    Ann Intern Med

    (1980)
  • R. Luukkainen et al.

    Treatment of rheumatoid arthritis (letter)

    Br Med J

    (1978)
  • K.R. Wilske et al.

    Remodeling the pyramid – a concept whose time has come

    J Rheumatol

    (1989)
  • J.F. Fries

    Reevaluating the therapeutic approach to rheumatoid arthritis: the ‘sawtooth’ strategy

    J Rheumatol

    (1990)
  • P. Emery et al.

    Early rheumatoid arthritis: time to aim for remission?

    Ann Rheum Dis

    (1995)
  • T. Sokka et al.

    Eligibility of patients in routine care for major clinical trials of anti-tumor necrosis factor alpha agents in rheumatoid arthritis

    Arthritis Rheum

    (2003)
  • F. Gogus et al.

    Inclusion criteria as widely used for rheumatoid arthritis clinical trials: patient eligibility in a Turkish cohort

    Clin Exp Rheumatol

    (2005)
  • U. Bergstrom et al.

    Lower disease activity and disability in Swedish patients with rheumatoid arthritis in 1995 compared with 1978

    Scand J Rheumatol

    (1999)
  • T. Pincus et al.

    Patients seen for standard rheumatoid arthritis care have significantly better articular, radiographic, laboratory, and functional status in 2000 than in 1985

    Arthritis Rheum

    (2005)
  • T. Sokka et al.

    Disease-modifying anti-rheumatic drug use according to the ‘sawtooth’ treatment strategy improves the functional outcome in rheumatoid arthritis: results of a long-term follow-up study with review of the literature

    Rheumatology

    (2000)
  • T. Heiberg et al.

    Seven year changes in health status and priorities for improvement of health in patients with rheumatoid arthritis

    Ann Rheum Dis

    (2005)
  • T.M. Sokka et al.

    Conventional monotherapy compared to a ‘sawtooth’ treatment strategy in the radiographic procession of rheumatoid arthritis over the first eight years

    Clin Exp Rheumatol

    (1999)
  • T. Sokka et al.

    Radiographic progression is getting milder in patients with early rheumatoid arthritis. Results of 3 cohorts over 5 years

    J Rheumatol

    (2004)
  • D. Krause et al.

    Response to methotrexate treatment is associated with reduced mortality in patients with severe rheumatoid arthritis

    Arthritis Rheum

    (2000)
  • L.T.H. Jacobsson et al.

    Treatment with TNF blockers and mortality risk in patients with rheumatoid arthritis

    Ann Rheum Dis

    (2007)
  • T. Sokka et al.

    Stable occurrence of knee and hip total joint replacement in Central Finland between 1986 and 2003: an indication of improved long-term outcomes of rheumatoid arthritis

    Ann Rheum Dis

    (2007)
  • E. da Silva et al.

    Declining use of orthopedic surgery in patients with rheumatoid arthritis? Results of a long-term, population-based assessment

    Arthritis Rheum

    (2003)
  • M.M. Ward

    Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983–2001

    Arthritis Rheum

    (2004)
  • R.J. Weiss et al.

    Orthopaedic surgery of the lower limbs in 49,802 rheumatoid arthritis patients: results from the Swedish National Inpatient Registry during 1987 to 2001

    Ann Rheum Dis

    (2006)
  • B. Fevang et al.

    Reduction in orthopedic surgery among patients with chronic inflammatory joint disease in Norway 1994-2004

    Arthritis Care Res

    (2007)
  • G. Kobelt et al.

    TNF inhibitors in the treatment of rheumatoid arthritis in clinical practice: costs and outcomes in a follow up study of patients with RA treated with etanercept or infliximab in southern Sweden

    Ann Rheum Dis

    (2004)
  • K. Puolakka et al.

    Early suppression of disease activity is essential for maintenance of work capacity in patients with recent-onset rheumatoid arthritis: five-year experience from the FIN-RACo trial

    Arthritis Rheum

    (2005)
  • T. Sokka et al.

    QUEST-RA: quantitative clinical assessment of patients with rheumatoid arthritis seen in standard rheumatology care in 15 countries

    Ann Rheum Dis

    (2007)
  • D.P.M. Symmons et al.

    Cases of early inflammatory polyarthritis should not be classified as having rheumatoid arthritis

    J Rheumatol

    (2003)
  • T. Allbutt et al.

    A system of medicine

    (1907)
  • F.C. Arnett et al.

    The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis

    Arthritis Rheum

    (1988)
  • B.J. Harrison et al.

    The performance of the 1987 ARA classification criteria for rheumatoid arthritis in a population based cohort of patients with early inflammatory polyarthritis

    J Rheumatol

    (1998)
  • A. Saraux et al.

    Ability of the American College of Rheumatology 1987 criteria to predict rheumatoid arthritis in patients with early arthritis and classification of these patients two years later

    Arthritis Rheum

    (2001)
  • P.S. Helliwell

    The semeiology of arthritis: discriminating between patients on the basis of their symptoms

    Ann Rheum Dis

    (1995)
  • K. Kaarela

    Prognostic factors and diagnostic criteria in early rheumatoid arthritis

    Scand J Rheumatol Supplement

    (1985)
  • T.T. Möttönen

    Prediction of erosiveness and rate of development of new erosions in early rheumatoid arthritis

    Ann Rheum Dis

    (1988)
  • P. Hannonen et al.

    Sulfasalazine in early rheumatoid arthritis

    Arthritis Rheum

    (1993)
  • K.P. Machold et al.

    Very recent onset arthritis–clinical, laboratory, and radiological findings during the first year of disease

    J Rheumatol

    (2002)
  • J.C. Buckland-Wright et al.

    Quantitative microfocal radiography defects changes in erosion area in patients with early rheumatoid arthritis treated with myocrisine

    J Rheumatol

    (1993)
  • C. Egsmose et al.

    Patients with rheumatoid arthritis benefit from early 2nd line therapy: 5 year followup of a prospective double blind placebo controlled study

    J Rheumatol

    (1995)
  • A. van der Heide et al.

    The effectiveness of early treatment with ‘second-line’ antirheumatic drugs: a randomized controlled trial

    Ann Intern Med

    (1996)
  • E.H. Choy et al.

    Treating rheumatoid arthritis early with disease modifying drugs reduces joint damage: a randomised double blind trial of sulphasalazine vs diclofenac sodium

    Clin Exp Rheumatol

    (2002)
  • Cited by (21)

    • Clinical features of rheumatoid arthritis

      2010, Medicine
      Citation Excerpt :

      Bone scintigraphy has a lower sensitivity in identifying articular inflammation by indicating areas of increased blood flow within the bone.14 Early aggressive treatment with disease-modifying antirheumatic drug therapies (DMARDs) can reduce the risk of complications, both articular and extra-articular.15 If inflammation is not controlled, RA results in characteristic joint and tendon destructive changes (Figure 2).

    View all citing articles on Scopus

    Modified and updated from: 1. Sokka T, Envalds M, Pincus T. Treatment of rheumatoid arthritis: a global perspective on the use of antirheumatic drugs. Mod Rheumatol. 2008 Apr 25. 2. Sokka T, Hannonen P, Möttönen T. Conventional disease-modifying antirheumatic drugs in early arthritis. Rheum Dis Clin North Am. 2005 Nov;31(4):729-44. Review.

    View full text