Radical Multiple Synovectomy More Effective than Disease-Modifying Drugs for Rheumatoid Arthritis In Short But Not Long Term

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Radical Multiple Synovectomy More Effective than Disease-Modifying Drugs for

Rheumatoid Arthritis In Short But Not Long Term

04/30/2004

By Jillian Lokere

Radical multiple synovectomy seems to promote a rapid remission of

rheumatoid arthritis, but after 5 years, it is no more effective than is

combination therapy with disease disease-modifying anti-rheumatic drugs

(DMARDs).

Synovectomy reduces rheumatoid arthritis (RA) disease activity by removing

joint synovial tissue that has become inflamed. A study in the 1980s by

MacEwen and colleagues found that traditional synovectomy of the finger or

knee joints had no long-term impact on disease progression. In this study,

Hiroshi Nakamura, MD, PhD, of the Institute of Medical Science, St. nn

University, Kanagawa, Japan, and colleagues evaluated the long-term impact

on RA progression of a new synovectomy procedure they developed, called

radical multiple synovectomy (RaMS).

Forty-two patients whose disease was unresponsive to DMARDs for at least 6

months were given RaMS and followed for an average of 7.3 years. Fourteen

patients who began and were responsive to triple DMARD therapy

(methotrexate, salazosulfapyridine, and bucillamine) during the same time

period were selected from patient records as controls. Before RaMS or start

of triple DMARD therapy, the following medications were given: prednisolone

4.1 to 4.7 mg daily (93% of RaMS, 93% of control); methotrexate 2.5 mg to

7.5 mg weekly (76% of RaMS, 50% of control); other DMARD (56% of RaMS, 35%

of control) and double DMARD therapy (35% of RaMS, 7% of control).

The RaMS procedure involved open synovectomy of an average of 11.1 joints

per patient. After surgery, prednisolone was continued unchanged while DMARD

dosages were increased in the RaMS group. In the control group, all patients

were taking prednisolone along with the triple DMARD regimen.

Remission was classified as lack of arthritic symptoms or fatigue,

regardless of erythrocyte sedimentation rate (ESR) and serum C-reactive

protein levels (CRP). Three months after RaMS or start of triple DMARD

therapy, 69% of patients in the surgery group, but none of the controls,

achieved remission (P<] < .05). After 36 months, 55% of RaMS patients were

still in remission compared with only 10% of controls ([P<] < .05). However,

after 5 years, both groups showed a similar remission rate of 30%.

Improvement in the number of swollen joints, number of painful joints, ESR,

CRP levels, rheumatoid factor levels and grip strength came more rapidly in

the RaMS group than in the control group, but only CRP levels and number of

painful joints were significantly different 7 years post-treatment. " The

effects of RaMS as measured by the clinical and laboratory findings appeared

very quickly and were superior to the controls in a short-term follow-up,

without any adverse events, " conclude Dr. Nakamura and colleagues. " Although

it was hoped that our [RaMS] procedure might offer a radical cure of RA,

RaMS was unable to alter the natural course of the disease.

Clin Exp Rheumatol 2004;22:1515-157