title: Rheumatoid atlantoaxial subluxation can be prevented by intensive use of traditional disease modifying antirheumatic drugs.
abstract: OBJECTIVE
  To evaluate the 5-year incidence of cervical spine disorders in patients with early rheumatoid arthritis (RA) treated by 2 different disease modifying antirheumatic drug (DMARD) strategies.
  
  
  METHODS
  In a national, multicenter, prospective FIN-RACo-trial, a cohort of 199 patients with early, clinically active RA was randomly assigned to treatment with a combination of 3 DMARD and prednisolone (Combi group) or with a single DMARD (Single group) with or without prednisolone, aiming to induce remission. After 2 years, the DMARD therapy was unrestricted. Lateral view cervical spine radiographs during full flexion and extension were taken at the 5-year followup visits. The presence of anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI), and subaxial subluxation (SAS) was assessed in the 149 patients with radiographs available (80 Single and 69 Combi).
  
  
  RESULTS
  At the 5-year visits, aAAS, AAI, and SAS were found in 13 (9%), 6 (4%), and 9 (6%) patients, respectively. The corresponding Single/Combi group ratios were 11/2, 5/1, and 5/4. Of the baseline data, only poor physical function [Health Assessment Questionnaire (HAQ); p = 0.024] and Single treatment strategy (p = 0.019) were significantly associated with aAAS. Worse HAQ scores and Disease Activity Score 28 values were found in patients who developed aAAS during the 5-year followup.
  
  
  CONCLUSIONS
  RA patients with sustained clinical disease activity and poor HAQ are at increased risk of developing aAAS. The development of aAAS during the first 5 years of RA was rare among the patients treated with a combination of DMARD for at least 2 years from the diagnosis. Intensive treatment with traditional DMARD prevents or retards the development of aAAS in patients with recent-onset RA.
authors.affiliation: Rheumatism Foundation Hospital, 18120 Heinola, Finland. markku.kauppi@reuma.fi
authors.forename: Markku J
authors.initials: MJ
authors.lastname: Kauppi
authors.forename: Marko H
authors.initials: MH
authors.lastname: Neva
authors.forename: Kari
authors.initials: K
authors.lastname: Laiho
authors.forename: Hannu
authors.initials: H
authors.lastname: Kautiainen
authors.forename: Reijo
authors.initials: R
authors.lastname: Luukkainen
authors.forename: Anna
authors.initials: A
authors.lastname: Karjalainen
authors.forename: Pekka J
authors.initials: PJ
authors.lastname: Hannonen
authors.forename: Marjatta
authors.initials: M
authors.lastname: Leirisalo-Repo
authors.forename: Markku
authors.initials: M
authors.lastname: Korpela
authors.forename: Kirsti
authors.initials: K
authors.lastname: Ilva
authors.forename: Timo
authors.initials: T
authors.lastname: Möttönen
mesh_terms: D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000188:drug therapy* / Q000503:physiopathology; D001175:Arthrography; D001268:Atlanto-Axial Joint / Q000187:drug effects* / Q000473:pathology / Q000503:physiopathology; D005260:Female; D006304:Health Status; D006801:Humans; D004204:Joint Dislocations / Q000188:drug therapy* / Q000209:etiology* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011239:Prednisolone / Q000008:administration & dosage; D011379:Prognosis; D011446:Prospective Studies; D016059:Range of Motion, Articular / Q000187:drug effects / Q000502:physiology; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
chemical_list: D000893:Anti-Inflammatory Agents; D018501:Antirheumatic Agents; D011239:Prednisolone