COBRA combination therapy in patients with early rheumatoid arthritis: long-term structural benefits of a brief intervention.
OBJECTIVE
The Combinatietherapie Bij Reumatoide Artritis (COBRA) trial demonstrated that step-down combination therapy with prednisolone, methotrexate, and sulfasalazine (SSZ) was superior to SSZ monotherapy for suppressing disease activity and radiologic progression of rheumatoid arthritis (RA). The current study was conducted to investigate whether the benefits of COBRA therapy were sustained over time, and to determine which baseline factors could predict outcome.


METHODS
All patients had participated in the 56-week COBRA trial. During followup, they were seen by their own rheumatologists and were also assessed regularly by study nurses; no treatment protocol was specified. Disease activity, radiologic damage, and functional ability were the primary outcome domains. Two independent assessors scored radiographs in sequence according to the Sharp/van der Heijde method. Outcomes were analyzed by generalized estimating equations on the basis of intent-to-treat, starting with data obtained at the last visit of the COBRA trial (56 weeks after baseline).


RESULTS
At the beginning of followup, patients in the COBRA group had a significantly lower mean time-averaged 28-joint disease activity score (DAS28) and a significantly lower median radiologic damage (Sharp) score compared with those in the SSZ monotherapy group. The functional ability score (Health Assessment Questionnaire [HAQ]) was similar in both groups. During the 4-5 year followup period, the time-averaged DAS28 decreased 0.17 points per year in the SSZ group and 0.07 in the COBRA group. The Sharp progression rate was 8.6 points per year in the SSZ group and 5.6 in the COBRA group. After adjustment for differences in treatment and disease activity during followup, the between-group difference in the rate of radiologic progression was 3.7 points per year. The HAQ score did not change significantly over time. Independent baseline predictors of radiologic progression over time (apart from treatment allocation) were rheumatoid factor positivity, Sharp score, and DAS28.


CONCLUSIONS
An initial 6-month cycle of intensive combination treatment that includes high-dose corticosteroids results in sustained suppression of the rate of radiologic progression in patients with early RA, independent of subsequent antirheumatic therapy.
Landewé
Robert B M
RB
Department of Internal Medicine/Rheumatology, PO Box 5800, University Hospital Maastricht, 6202 AZ Maastricht, The Netherlands. RLAN@SINT.AZM.NL
Boers
Maarten
M
Verhoeven
Arco C
AC
Westhovens
Rene
R
van de Laar
Mart A F J
MA
Markusse
Harry M
HM
van Denderen
J Christiaan
JC
Westedt
Marie Louise
ML
Peeters
Andre J
AJ
Dijkmans
Ben A C
BA
Jacobs
Piet
P
Boonen
Annelies
A
van der Heijde
Désirée M F M
DM
van der Linden
Sjef
S
D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage*; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000188:drug therapy*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage*; D008875:Middle Aged; D011237:Predictive Value of Tests; D011239:Prednisolone / Q000008:administration & dosage*; D011859:Radiography; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D012460:Sulfasalazine / Q000008:administration & dosage*; D016896:Treatment Outcome
D000893:Anti-Inflammatory Agents; D018501:Antirheumatic Agents; D012460:Sulfasalazine; D011239:Prednisolone; D008727:Methotrexate