title: Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry.
abstract: BACKGROUND
  Treat to target (T2T) is widely accepted as the standard of care for patients with rheumatoid arthritis (RA) and has been shown to be more effective than traditional routine care. The objective of this study was to compare the effectiveness of two T2T strategies in patients with early RA: a step-up approach starting with methotrexate (MTX) monotherapy (cohort I) versus an initial disease-modifying antirheumatic drug combination approach (cohort II).
  
  
  METHODS
  A total of 128 patients from cohort II were case-control-matched with 128 patients from cohort I on gender, age, and baseline disease activity. Twelve-month follow-up data were available for 121 patients in both cohorts. The primary outcome was the proportion of patients having reached at least one 28-joint Disease Activity Score (DAS28) score <2.6 (remission) during 12 months of follow-up. Secondary outcomes were time until remission was achieved and mean DAS28 scores at 6- and 12-month follow-up.
  
  
  RESULTS
  After 12 months of follow-up, remission was reached at least once in 77.3 % of the patients in cohort II versus 71.9 % in cohort I (P = 0.31). Median time until first remission was 17 weeks in cohort II versus 27 weeks in cohort I (P = 0.04). A significant time by strategy interaction was found in mean DAS28 scores. Post hoc analysis revealed a significant difference in mean DAS28 scores between both cohorts at 6 months (P = 0.04), but not at 12 months (P = 0.36).
  
  
  CONCLUSIONS
  The initial combination strategy resulted in a comparable remission rate after 1 year but a significantly shorter time until remission. At 6 months, mean DAS28 scores were lower in patients with initial combination treatment than in those with step-up therapy. At 12 months, no significant differences remained in mean DAS28 scores or the proportion of patients in remission.
authors.affiliation: Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. lmm.steunebrink@mst.nl.|Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands. lmm.steunebrink@mst.nl.
authors.forename: L M M
authors.initials: LM
authors.lastname: Steunebrink
authors.affiliation: Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. g.steunenberg-versteeg@mst.nl.|Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands. g.steunenberg-versteeg@mst.nl.
authors.forename: G A
authors.initials: GA
authors.lastname: Versteeg
authors.affiliation: Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. h.vonkeman@mst.nl.|Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands. h.vonkeman@mst.nl.
authors.forename: H E
authors.initials: HE
authors.lastname: Vonkeman
authors.affiliation: Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands. p.m.tenklooster@utwente.nl.
authors.forename: P M
authors.initials: PM
authors.lastname: Ten Klooster
authors.affiliation: Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. h.kuper@mst.nl.
authors.forename: H H
authors.initials: HH
authors.lastname: Kuper
authors.affiliation: Department of Rheumatology, Isala Klinieken, Zwolle, The Netherlands. te.r.zijlstra@isala.nl.
authors.forename: T R
authors.initials: TR
authors.lastname: Zijlstra
authors.affiliation: Department of Rheumatology, Bernhoven, Uden, The Netherlands. p.vanriel@bernhoven.nl.
authors.forename: P L C M
authors.initials: PL
authors.lastname: van Riel
authors.affiliation: Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. m.vandelaar@mst.nl.|Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands. m.vandelaar@mst.nl.
authors.forename: M A F J
authors.initials: MA
authors.lastname: van de Laar
mesh_terms: D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D016022:Case-Control Studies; D015331:Cohort Studies; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage; D008875:Middle Aged; D012042:Registries; D012074:Remission Induction
chemical_list: D018501:Antirheumatic Agents; D008727:Methotrexate