RESEARCH - Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early RA

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Rheumatology Advance Access originally published online on November 26, 2007

Rheumatology 2008 47(1):59-64; doi:10.1093/rheumatology/kem288

Daily practice effectiveness of a step-down treatment in comparison with a

tight step-up for early rheumatoid arthritis

P. Verschueren, G. Esselens and R. Westhovens

Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium.

Abstract

Objective. To study prospectively the daily practice effectiveness of a

step-down early rheumatoid arthritis (RA) treatment strategy.

Methods. Patients with severe RA and no contra-indications were proposed

step-down therapy, the others step-up. Step-down patients received a

modified combination therapy in early RA (COBRA) regimen: sulphasalazine

(SPS), 2 g daily, and methotrexate (MTX), 15 mg weekly, combined with

step-down oral prednisolone (start 60 mg daily, fast tapering to 7.5 mg over

6 weeks, discontinuation from week 28). At week 40, patients were randomized

to maintenance therapy with either SPS or MTX if disease activity score-28

(DAS28) was acceptably low. The step-up group started disease-modifying

anti-rheumatic drug (DMARD) monotherapy. In both groups, treatment was

adjusted at follow-up, based on DAS28. DAS28, functionality Health

Assessment Questionnaire (HAQ), adverse events, DMARD changes and steroid

use were registered 4-monthly for 2 yrs.

Results. Ninteen patients received step-down and 52 step-up treatment. More

patients completed the first year without unplanned DMARD changes and

without dosage adjustment and fewer had DMARD changes due to side effects or

inefficacy in the step-down group compared with step-up, whereas the number

of adverse events was comparable. MTX proved to be the most effective

maintenance therapy after step-down. The DAS response, proportion of

patients in remission, HAQ response and proportion of patients without

disability at 4 months was higher in the step-down group.

Conclusions. In daily practice, a step-down treatment strategy for early RA

is more effective than a step-up approach.

http://rheumatology.oxfordjournals.org/cgi/content/abstract/47/1/59

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