Early, Aggressive RA Treatment Best
Three-Drug Combination May Produce More Remissions, Less Joint Damage
July 7, 2004 -- When it comes to treating rheumatoid arthritis, there is growing evidence that the best approach is to hit it early and hit it hard.
New research from Finland shows that aggressive treatment soon after diagnosis with a combination of drugs is more effective for slowing disease progression than treating with only one drug or delaying treatment.
Rheumatoid arthritis patients treated early with three different disease-modifying antirheumatic drugs (DMARDs) were more than twice as likely to have achieved remissions at two years than patients treated with one such drug. At five years, patients taking the combination of drugs had less joint damage and reported less pain and loss of mobility.
But remission rates did not improve for patients who switched from one drug to the combination of drugs two years into treatment.
"Window of Opportunity"
Researchers concluded that the window of opportunity for improved outcomes with the combination approach appears to close as the disease progresses. Their findings are published in the July issue of the journal Arthritis and Rheumatism.
"We have shown that early institution of DMARD combinations in patients with clinically active rheumatoid arthritis is favorable not only in terms of clinical disease activity, but also in terms of long-term radiologic progression," researcher Markku Korpela, MD, PhD, and colleagues noted.
But Arthritis Foundation president John H. Klippel, MD, says even with the best available treatment approaches, outcomes remain disappointing for too many patients. In the Finnish study, 40% of patients treated early with the combination approach had achieved a remission two years into treatment, compared with 18% of patients treated with only one drug. Five years into treatment there was no significant difference in remission rates between the two groups -- 28% in the early, combination treatment patients vs. 21% in those initially treated with one drug.
In Korpela's study, the combination group received methotrexate, sulfasalazine, and hydroxychloroquine while the single-drug group took only sulfasalazine.
Klippel tells WebMD that the early treatment, combination approach represents an "incremental advance" over earlier treatments.
"Ten years ago it wasn't even clear that you could slow joint damage with treatment," he says. "We have come a long way, but this is not the major breakthrough that we are searching for. What we want is to see a much larger percentage of patients achieving true remissions."
Klippel says specialists now understand the importance of early diagnosis and treatment, but he adds that most rheumatoid arthritis patients still don't begin treatment as soon as they should.
"In most cities in this country patients are likely to face long delays in getting in to see a rheumatologist," he says. "We are talking about weeks or months before someone gets evaluated and starts treatment, and this is too long."
Future Treatment Advances
But Klippel says he's optimistic about future treatment advances. In addition to DMARDs, which have been around for years, several new drugs in a class known as biologic response modifiers, or biologics, have more recently been approved for the treatment of rheumatoid arthritis. They include the drugs Enbrel, Humira, Kineret, and Remicade.
Earlier this year, researchers in Sweden reported much better outcomes among patients treated with a combination of the DMARD methotrexate and the biologic Enbrel than were seen among patients treated with methotrexate alone.
Korpela and colleagues note that the newer drugs are also much more expensive than the older ones. They conclude that studies comparing combination treatments with and without the biologics are "urgently needed."