title: Comparison of treatment strategies in early rheumatoid arthritis: a randomized trial.
abstract: BACKGROUND
  In patients with early rheumatoid arthritis, initial combination therapies provide earlier clinical improvement and less progression of joint damage after 1 year compared with initial monotherapies (as demonstrated in the BeSt study).
  
  
  OBJECTIVE
  To evaluate whether the initial clinical and radiographic efficacy of combination therapies could be maintained during the second year of follow-up in patients with early rheumatoid arthritis.
  
  
  METHODS
  Randomized, controlled clinical trial with blinded assessors.
  
  
  METHODS
  18 peripheral and 2 university medical centers in the Netherlands.
  
  
  METHODS
  508 patients with early active rheumatoid arthritis.
  
  
  METHODS
  Sequential monotherapy (group 1), step-up combination therapy (group 2), initial combination therapy with tapered high-dose prednisone (group 3), or initial combination therapy with infliximab (group 4). Trimonthly treatment adjustments were made to achieve low disease activity.
  
  
  METHODS
  Primary end points were functional ability (Health Assessment Questionnaire) and Sharp-van der Heijde score for radiographic joint damage.
  
  
  RESULTS
  Groups 3 and 4 had more rapid clinical improvement during the first year; all groups improved further to a mean functional ability score of 0.6 (overall, P = 0.257) and 42% were in remission (overall, P = 0.690) during the second year. Progression of joint damage remained better suppressed in groups 3 and 4 (median scores of 2.0, 2.0, 1.0, and 1.0 in groups 1, 2, 3, and 4, respectively [P = 0.004]). After 2 years, 33%, 31%, 36%, and 53% of patients in groups 1 through 4, respectively, were receiving single-drug therapy for initial treatment. There were no significant differences in toxicity.
  
  
  CONCLUSIONS
  Patients and physicians were aware of the allocated group, and the assessors were blinded.
  
  
  CONCLUSIONS
  Currently available antirheumatic drugs can be highly effective in patients with early rheumatoid arthritis in a setting of tight disease control. Initial combination therapies seem to provide earlier clinical improvement and less progression of joint damage, but all treatment strategies eventually showed similar clinical improvements. In addition, combination therapy can be withdrawn successfully and less treatment adjustments are needed than with initial monotherapies.
authors: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands. y.p.m.goekoop@lumc.nl
authors: Yvonne P M
authors: YP
authors: Goekoop-Ruiterman
authors: Jeska K
authors: JK
authors: de Vries-Bouwstra
authors: Cornelia F
authors: CF
authors: Allaart
authors: Derkjen
authors: D
authors: van Zeben
authors: Pit J S M
authors: PJ
authors: Kerstens
authors: J Mieke W
authors: JM
authors: Hazes
authors: Aelko H
authors: AH
authors: Zwinderman
authors: André J
authors: AJ
authors: Peeters
authors: Johanna M
authors: JM
authors: de Jonge-Bok
authors: Constant
authors: C
authors: Mallée
authors: Wim M
authors: WM
authors: de Beus
authors: Peter B J
authors: PB
authors: de Sonnaville
authors: Jacques A P M
authors: JA
authors: Ewals
authors: Ferdinand C
authors: FC
authors: Breedveld
authors: Ben A C
authors: BA
authors: Dijkmans
mesh_terms: D000893:Anti-Inflammatory Agents / Q000009:adverse effects / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000009:adverse effects / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000188:drug therapy*; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D006801:Humans; D000069285:Infliximab; D011241:Prednisone / Q000009:adverse effects / Q000627:therapeutic use; D011859:Radiography; D016037:Single-Blind Method; D016896:Treatment Outcome
chemical_list: D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D000069285:Infliximab; D011241:Prednisone