title: Intra-articular glucocorticoid injections should not be neglected in the remission targeted treatment of early rheumatoid arthritis: a post hoc analysis from the NEO-RACo trial.
abstract: OBJECTIVE
  To study the effects of neglecting intra-articular glucocorticoid injections (IAGCIs) into swollen joints in early rheumatoid arthritis (RA).
  
  
  METHODS
  Ninety-nine patients with early, DMARD naive RA were treated, aiming at remission, with methotrexate, sulfasalazine, hydroxychloroquine, low-dose oral prednisolone and, when needed, IAGCIs for 2 years, and randomised to receive infliximab or placebo from weeks 4 to 26. During each of the 15 study visits, patients were scored retrospectively 0.2-0.4 points (depending on the number of non-injected joints) if IAGCIs to all swollen joints were not given. Patients were divided into tertiles by their cumulative scores for neglected injections (CSNI) over 24 months. 28-joint disease activity score (DAS28) area under the curve (AUC) between 0-24 months, remission rates, changes in quality of life, and radiological changes during the follow-up were assessed. Trends across tertiles of CSNI were tested with generalised linear models.
  
  
  RESULTS
  Higher CSNI was associated with lower strict remission rates (p=0.005), and lower quality of life (p=0.004) at 24 months, and higher DAS28 AUC (p<0.001) during the follow-up. At 24 months, DAS28 remission rates were 90%, 93% and 76% (p=0.081), and strict remission rates were 74%, 77% and 39% by tertiles of CSNI. No significant differences were observed in radiological progression (p=0.089). IAGCIs were well tolerated.
  
  
  CONCLUSIONS
  Neglecting IAGCIs into swollen joints is associated with lower remission rates, higher disease activity, and lower quality of life. Hence, IAGCIs should be used as an integral part of the targeted treatment of early RA.
authors: Department of Internal Medicine, University of Turku and Turku University Hospital, Finland. laura.kuusalo@utu.fi.
authors: Laura A
authors: LA
authors: Kuusalo
authors: South-Karelia Central Hospital, Lappeenranta, Finland.
authors: Kari T
authors: KT
authors: Puolakka
authors: Unit of Primary Health Care, University of Helsinki and Helsinki University Hospital; Department of General Practice, University of Helsinki; and Unit of Primary Health Care, Kuopio University Hospital, Finland.
authors: Hannu
authors: H
authors: Kautiainen
authors: Department of Medicine, Oulu University Hospital, Finland.
authors: Eeva M
authors: EM
authors: Alasaarela
authors: Jyväskylä Central Hospital, Jyväskylä, Finland.
authors: Pekka J
authors: PJ
authors: Hannonen
authors: Department of Rheumatology, University of Helsinki and Helsinki University Hospital, Finland.
authors: Heikki A
authors: HA
authors: Julkunen
authors: Department of Medicine, Kuopio University Hospital, Finland.
authors: Oili A
authors: OA
authors: Kaipiainen-Seppänen
authors: Department of Internal Medicine, Centre for Rheumatic Diseases, Tampere University Hospital, Finland.
authors: Markku M
authors: MM
authors: Korpela
authors: Department of Internal Medicine, University of Turku and Turku University Hospital, Finland.
authors: Timo T
authors: TT
authors: Möttönen
authors: ORTON Orthopaedic Hospital, Helsinki, Finland.
authors: Leena H
authors: LH
authors: Paimela
authors: Department of Rheumatology, University of Helsinki and Helsinki University Hospital, Finland.
authors: Ritva L
authors: RL
authors: Peltomaa
authors: Satakunta Central Hospital, Rauma, Finland.
authors: Timo K
authors: TK
authors: Yli-Kerttula
authors: Department of Rheumatology, University of Helsinki and Helsinki University Hospital, Finland.
authors: Marjatta
authors: M
authors: Leirisalo-Repo
authors: Department of Internal Medicine, Centre for Rheumatic Diseases, Tampere University Hospital; and School of Medicine, University of Tampere, Finland.
authors: Vappu M
authors: VM
authors: Rantalaiho
mesh_terms: D000328:Adult; D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D006886:Hydroxychloroquine / Q000627:therapeutic use; D000069285:Infliximab / Q000627:therapeutic use; D007270:Injections, Intra-Articular; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use; D008875:Middle Aged; D011788:Quality of Life; D012074:Remission Induction / Q000379:methods; D012460:Sulfasalazine / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents; D005938:Glucocorticoids; D012460:Sulfasalazine; D006886:Hydroxychloroquine; D000069285:Infliximab; D008727:Methotrexate