title: The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study.
abstract: OBJECTIVE
  To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up.
  
  
  METHODS
  508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤ 2.4 during ≥ 6 months taper to maintenance dose; if DAS <1.6 during ≥ 6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages.
  
  
  RESULTS
  After 5 years, 48% of patients were in clinical remission (DAS <1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2-5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response.
  
  
  CONCLUSIONS
  Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.
authors.affiliation: Department of Rheumatology, C-01-R, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands. n.b.klarenbeek@lumc.nl
authors.forename: Naomi B
authors.initials: NB
authors.lastname: Klarenbeek
authors.forename: Melek
authors.initials: M
authors.lastname: Güler-Yüksel
authors.forename: Sjoerd M
authors.initials: SM
authors.lastname: van der Kooij
authors.forename: K Huub
authors.initials: KH
authors.lastname: Han
authors.forename: H Karel
authors.initials: HK
authors.lastname: Ronday
authors.forename: Pit J S M
authors.initials: PJ
authors.lastname: Kerstens
authors.forename: Patrick E H
authors.initials: PE
authors.lastname: Seys
authors.forename: Tom W J
authors.initials: TW
authors.lastname: Huizinga
authors.forename: Ben A C
authors.initials: BA
authors.lastname: Dijkmans
authors.forename: Cornelia F
authors.initials: CF
authors.lastname: Allaart
mesh_terms: D000328:Adult; D000368:Aged; 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*; D018450:Disease Progression; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D000069285:Infliximab; D008297:Male; D008727:Methotrexate / Q000009:adverse effects / Q000627:therapeutic use; D008875:Middle Aged; D011241:Prednisone / Q000009:adverse effects / Q000627:therapeutic use; D011788:Quality of Life; D011859:Radiography; D012074:Remission Induction; D012720:Severity of Illness Index; D016037:Single-Blind Method; 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; D008727:Methotrexate