title: Patients with stable long-standing rheumatoid arthritis continue to deteriorate despite intensified treatment with traditional disease modifying anti-rheumatic drugs--results of the British Rheumatoid Outcome Study Group randomized controlled clinical trial.
abstract: OBJECTIVE
  Patients with rheumatoid arthritis (RA) should start treatment early with the aim of suppressing the inflammatory process completely. It is not known if this strategy should, or can, be continued in later disease.
  
  
  METHODS
  In a multicentre, randomized, observer-blinded, controlled trial, 466 patients with established RA (>5 yr), on stable therapy for at least 6 months, were randomized to adequate symptom control/shared care setting (SCSC) or aggressive treatment/hospital setting (ATH). All were reviewed annually by a rheumatologist. The primary outcome after 3 yr was the Health Assessment Questionnaire (HAQ). Others included the OMERACT core set and the Disease Activity Score (DAS) 28.
  
  
  RESULTS
  Three hundred and ninety-nine patients completed the trial. There was a significant deterioration in HAQ in both arms. Only the physician global score differed between the arms.
  
  
  CONCLUSIONS
  The trial showed no additional benefit of intensified treatment with traditional disease modifying anti-rheumatic drugs (DMARDs) in patients with stable, established RA. It proved hard to suppress C-reactive protein levels. Patients in the SCSC arm were able to initiate treatment changes when their symptoms deteriorated without frequent hospital assessment. Pending further evidence, the model of shared care with annual hospital review is as good as 4-monthly hospital review for these patients.
authors.affiliation: Arc Epidemiology Unit, University of Manchester, Manchester M13 9PT, UK. deborah.symmons@man.ac.uk
authors.forename: D
authors.initials: D
authors.lastname: Symmons
authors.forename: K
authors.initials: K
authors.lastname: Tricker
authors.forename: M
authors.initials: M
authors.lastname: Harrison
authors.forename: C
authors.initials: C
authors.lastname: Roberts
authors.forename: M
authors.initials: M
authors.lastname: Davis
authors.forename: P
authors.initials: P
authors.lastname: Dawes
authors.forename: A
authors.initials: A
authors.lastname: Hassell
authors.forename: S
authors.initials: S
authors.lastname: Knight
authors.forename: D
authors.initials: D
authors.lastname: Mulherin
authors.forename: D L
authors.initials: DL
authors.lastname: Scott
mesh_terms: D000368:Aged; D000465:Algorithms; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000503:physiopathology; D003695:Delivery of Health Care / Q000458:organization & administration*; D004334:Drug Administration Schedule; D004739:England; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization; D006801:Humans; D007373:Interinstitutional Relations; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010044:Outpatient Clinics, Hospital; D010348:Patient Care Team / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration; D012720:Severity of Illness Index; D016037:Single-Blind Method; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents