RESEARCH - Clinical and radiological efficacy of initial versus delayed treatment with Remicade plus MTX in patients with early RA

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Ann Rheum Dis. Published Online First: 17 October 2008.

doi:10.1136/ard.2008.093294

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Extended Report

Clinical and radiological efficacy of initial versus delayed treatment

with infliximab plus methotrexate in patients with early rheumatoid

arthritis

Sjoerd M van der Kooij 1*, Saskia le Cessie 1, PM

Goekoop-Ruiterman 2, Jeska K De Vries-Bouwstra 3, Derkjen van Zeben 4,

Pit JSM Kerstens 5, J MW Hazes 6, Dirkjan van Schaardenburg 7, Ferry C

Breedveld 8, Ben AC Dijkmans 3 and Cornelia F Allaart 1

1 LUMC, Netherlands

2 Leiden University Medical Center, Netherlands

3 VUmc, Netherlands

4 Sint Franciscus Hospital, Netherlands

5 Jan van Breemen, Netherlands

6 University Hospital Rotterdam, Netherlands

7 Jan van Breemen Institute, Netherlands

8 University Hospital Leiden, Netherlands

Abstract

Objectives: To compare the clinical and radiological efficacy of

initial versus delayed treatment with methotrexate (MTX) and

infliximab (IFX) in patients with recent onset rheumatoid arthritis

(RA).

Methods: In a post-hoc analysis of the BeSt study, 117 patients who

started initial MTX+IFX were compared with 67 patients who started

MTX+IFX treatment after failing (disease activity score [DAS] >2.4;

median delay to IFX: 13 months) on 3 traditional DMARDs. If the DAS

remained >2.4, the protocol dictated IFX dose increases to 6, 7.5, and

10mg/kg. In case of a DAS 2.4 for 6 months, IFX was tapered and

finally stopped. We aimed to correct for allocation bias using

propensity scores. Functional ability was measured by the Health

Assessment Questionnaire (HAQ), radiological progression by Sharp/van

der Heijde scoring (SHS).

Results: Baseline differences between the initial and delayed groups

were no longer significant after propensity score adjustment. Three

years after baseline, patients treated with initial MTX+IFX

experienced more improvement in HAQ over time, and were less likely to

have SHS progression than patients treated with delayed MTX+IFX

(P=0.034). Two years after IFX initiation, more patients in the

initial group compared with the delayed group could discontinue IFX

after a good response (56% versus 29%, P=0.008).

Conclusions: The results of this post-hoc analysis suggest that using

MTX+IFX as initial treatment for recent onset RA patients is more

effective than reserving MTX+IFX for patients who failed on

traditional DMARDs, with more HAQ improvement over time, more IFX

discontinuation and less progression of joint damage.

http://ard.bmj.com/cgi/content/abstract/ard.2008.093294v1?papetoc

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