title: Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): A randomized, controlled trial.
abstract: OBJECTIVE
  Several treatment strategies have proven value in the amelioration of rheumatoid arthritis (RA), but the optimal strategy for preventing long-term joint damage and functional decline is unclear. We undertook this study to compare clinical and radiographic outcomes of 4 different treatment strategies, with intense monitoring in all patients.
  
  
  METHODS
  In a multicenter, randomized clinical trial, 508 patients were allocated to 1 of 4 treatment strategies: sequential disease-modifying antirheumatic drug monotherapy (group 1), step-up combination therapy (group 2), initial combination therapy with tapered high-dose prednisone (group 3), and initial combination therapy with the tumor necrosis factor antagonist infliximab (group 4). Treatment adjustments were made every 3 months in an effort to obtain low disease activity (a Disease Activity Score in 44 joints of < or =2.4).
  
  
  RESULTS
  Initial combination therapy including either prednisone (group 3) or infliximab (group 4) resulted in earlier functional improvement than did sequential monotherapy (group 1) and step-up combination therapy (group 2), with mean scores at 3 months on the Dutch version of the Health Assessment Questionnaire (D-HAQ) of 1.0 in groups 1 and 2 and 0.6 in groups 3 and 4 (P < 0.001). After 1 year, mean D-HAQ scores were 0.7 in groups 1 and 2 and 0.5 in groups 3 and 4 (P = 0.009). The median increases in total Sharp/Van der Heijde radiographic joint score were 2.0, 2.5, 1.0, and 0.5 in groups 1-4, respectively (P < 0.001). There were no significant differences in the number of adverse events and withdrawals between the groups.
  
  
  CONCLUSIONS
  In patients with early RA, initial combination therapy including either prednisone or infliximab resulted in earlier functional improvement and less radiographic damage after 1 year than did sequential monotherapy or step-up combination therapy.
authors.affiliation: Leiden University Medical Center, Leiden, The Netherlands. y.p.m.goekoop@lumc.nl
authors.forename: Y P M
authors.initials: YP
authors.lastname: Goekoop-Ruiterman
authors.forename: J K
authors.initials: JK
authors.lastname: de Vries-Bouwstra
authors.forename: C F
authors.initials: CF
authors.lastname: Allaart
authors.forename: D
authors.initials: D
authors.lastname: van Zeben
authors.forename: P J S M
authors.initials: PJ
authors.lastname: Kerstens
authors.forename: J M W
authors.initials: JM
authors.lastname: Hazes
authors.forename: A H
authors.initials: AH
authors.lastname: Zwinderman
authors.forename: H K
authors.initials: HK
authors.lastname: Ronday
authors.forename: K H
authors.initials: KH
authors.lastname: Han
authors.forename: M L
authors.initials: ML
authors.lastname: Westedt
authors.forename: A H
authors.initials: AH
authors.lastname: Gerards
authors.forename: J H L M
authors.initials: JH
authors.lastname: van Groenendael
authors.forename: W F
authors.initials: WF
authors.lastname: Lems
authors.forename: M V
authors.initials: MV
authors.lastname: van Krugten
authors.forename: F C
authors.initials: FC
authors.lastname: Breedveld
authors.forename: B A C
authors.initials: BA
authors.lastname: Dijkmans
mesh_terms: D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D000069285:Infliximab; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000627:therapeutic use; D011859:Radiography; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D005938:Glucocorticoids; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D011241:Prednisone