RESEARCH - Speculations on why early treatment of RA is uniquely effective

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Journal of Rheumatolgy

Editorial

Nov 2008

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Speculations on Why Early Treatment of Rheumatoid Arthritis Is

Uniquely Effective

JOHN T. SHARP, MD,

Affiliate Professor of Medicine,

University of Washington School of Medicine,

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Is it a greater remission rate, or are we preventing onset of

rheumatoid arthritis?

Dating back to 1909 there have been multiple reports that early

treatment of " rheumatoid arthritis " (RA) is uniquely effective1,4.

Recent reports suggest that early treatment induces a high remission

rate and slows the progression of structural damage during and after

the initial treatment phase. In 1999, Finnish investigators reported

that 195 patients randomized to 2 treatments, sulfasalazine (SSZ)

alone or a combination of SSZ, methotrexate (MTX), hydroxychloroquine

(HCQ), and low-dose prednisolone, had remission rates of 35% and 42%,

respectively, when treated within the first 4 months after disease

onset5. Those who received monotherapy between 4 and 24 months after

onset had a remission rate of only 11%, while those treated with the

combination continued to have a remission rate of 42%. Progression of

structural damage was significantly slower in the combination group

during the 2 years of treatment on the protocol and persisted for 3

years longer6. Was the remission rate observed in the FIN-RACo study

uniquely high? Table 1 lists data on American College of Rheumatology

(ACR) improvement and remission rates for comparison7-12. Remission

rates were reported for only 2 studies; however, accepting ACR70 and

ACR90 as representing the highest possible remission rate, these

studies are strikingly different from the FIN-RACo8,9. Eberhardt and

colleagues observed remissions of 6 months or longer in 20% of 183

patients seen in the first 6 months of disease and treated without

biologics8. The Hetland report on patients in the first 6 months of

disease is further evidence that early treatment induces a high

remission rate9. In other reports ACR70 rates were not above 26%.

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http://www.jrheum.com/subscribers/08/11/2090.html

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