When it Comes to Treatment, Early is Best

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When it Comes to Treatment, Early is Best

by Mann and Donna Rae Siegfried

Arthritis Today, June 2005

Receiving RA treatment sooner rather than later may be your key to

remission.

The " Take Control " Timeline

A hot topic among rheumatologists lately is whether when you treat

rheumatoid arthritis (RA) matters as much as how you treat it. Some

believe strongly in the benefits of early treatment, prescribing an

aggressive regimen of RA drugs during what is called " the window of

opportunity. " Doing so, they maintain, just may stop the disease in its

tracks.

" I am a strong believer in the window of opportunity, which probably

spans two years after symptom onset, " says Salahuddin Kazi, MD,

associate professor of internal medicine and chief of rheumatology at

the Dallas VA Medical Center. " If RA goes untreated for two years, the

majority of people with RA will develop joint erosion, indicating

disease progression. "

" The debate over whether a window of opportunity exists is semantics to

some extent, " says Arthur Kavanaugh, MD, rheumatologist and director of

the Center for Innovative Therapy at the University of California, San

Diego. " Some people don't like the term because people with active

disease can -- and should -- always be treated, even beyond the

two-year mark. "

Treating RA as early as possible is not a new concept. In 1989, a study

published in The Lancet emphasized the importance of starting a regimen

of antirheumatic drugs early. The drugs commonly used then were

hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine);

methotrexate wasn't yet an option, and biologics were not yet

developed. The main difference between discussions of early treatment

15 to 20 years ago and today are the drugs available for aggressive

treatment, says Dr. Kavanaugh.

Early, aggressive treatment is particularly important for those who

will develop a more serious disease. Figuring out who those patients

are is quite a challenge, but there are some guiding principles. " I

think it's pretty clear right now that if a patient has antibodies to

rheumatoid factor (RF) or cyclic citrullinated proteins (anti-CCP) at

any time during the course of disease -- from day one to 12 weeks or 12

years -- then he has a greater risk for persistent disease that is

worse and more destructive, " says Paget, MD, rheumatologist and

physician-in-chief of the Hospital for Special Surgery in New York

City. " Those patients need aggressive therapy that's constantly

monitored. "

A recent study of adalimumab (Humira) plus methotrexate showed one in

two people with early RA -- diagnosed less than three years earlier --

achieved a clinical remission at two years. More than 60 percent of the

patients showed at least a 50-percent improvement in symptoms. The

effect with combination therapy was observed as early as two weeks, and

these differences were sustained throughout the two-year study.

Another study, the Definitive Intervention in New-Onset Rheumatoid

Arthritis (DINORA) trial, is reviewing the use of infliximab (Remicade)

in people with very early inflammatory RA (those who had it fewer than

14 weeks) to see if it can prevent the development of destructive

disease.

While it's ideal to initiate treatment as early as possible, aggressive

treatment throughout the course of the disease is essential, say the

experts.

" If you're past that two-year mark with no treatment or treatment that

wasn't aggressive enough, all is not lost, " says Dr. Kavanaugh.