The Benefit of Very Early Referral and Therapy with Disease Modifying Antirheumatic Drugs in Patients with Early Rheumatoid Arthritis

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The Benefit of Very Early Referral and Therapy with Disease Modifying

Antirheumatic Drugs in Patients with Early Rheumatoid Arthritis

Category:  17 RA‹treatment

P K Nell1, Klaus P Machold1, e Eberl2, Tanja Stamm1,

Uffmann3, f S Smolen1

1Department of Rheumatology, University Hospital, Vienna, Austria2Center of

Rheumatic diseases, Lainz Hosital, Vienna, Austria3Department of Radiology,

University Hospital, Vienna, Austria

Presentation Number: 846

Poster Board Number: 311

Keywords: Early Rheumatoid Arthritis, DMARD Therapy of Rheumatoid Arthritis

Background: Evidence suggests that delay of disease modifying anti rheumatic

drug (DMARD) therapy may be a major contributing factor for poor outcome in

rheumatoid arthritis (RA). Most rheumatologists today recommend early

introduction of DMARDs, referring to results of clinical trials on early RA

patients with a disease duration of up to three years until DMARD start. To

this date though, there is little data actually comparing the outcome of

strictly very early intervention to somewhat delayed intervention in

patients with yet relatively early disease.

Objective: In this case control study we have tested if such a ³window of

opportunity² may exist, and thus compared disease activity, joint

destruction and functional outcome in patients with very early start of

disease- modifying therapy to age- and gender- matched patients who have

experienced a short delay.

Methods: 20 VERA (=very early RA) patients (pts) with a mean disease

duration of 3 months until initiation of DMARDs were matched (age and

gender) to a group of 20 LERA pts (=late early RA) that had experienced a

slightly delayed DMARD start (mean 20 months). The core set of disease

activity measures for RA clinical trials were assessed every 3 months for

the first year and yearly thereafter. The disease activity score (DAS) was

then calculated and the ACR Improvement criteria (20%, 50%) were applied. At

yearly intervals the joint destruction in relation to baseline was assessed

radiologically by a multidisciplinary, blinded team, and scored by the

Larsen method. Results: 45% of the VERA group were RF positive at baseline,

and 40% of the LERA (p>0.05). Already after 3 months of DMARD therapy we

found a significant difference of improvement in favor of the VERA group in

the DAS as well as the functional assessment (HAQ score), and the ACR

response. This trend continued over the study period and at study end the

DAS showed an improvement of 2.8+-1.5 in the VERA vs. 1.7+-1.2 (mean+-SD) in

the LERA group (p<0.05). At this time, the ACR 20% improvement criteria were

fulfilled by 70% of the VERA group, but only 40% of the LERA pts

(p<0.05).The Larsen Score also showed a statistically significant difference

of progression between the two groups already after one year from baseline.

At 36 months, 8 VERA pts showed radiologically detectable erosions, as

opposed to 15 LERA pts (p<0.05).

Conclusion: The results obtained showed that despite similar therapies, the

most important difference between the two groups occurred within the fist

year and particularly in the first three months of treatment, and that the

slope of improvement thereafter parallels. Our results indicate that there

is a window of opportunity for successful treatment of RA. Very early

introduction of DMARDs seems highly beneficial compared to even relatively

short delay.