RESEARCH - Tight control and intensified COBRA combination treatment in early RA: 90% remission in a pilot trial

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Ann Rheum Dis. 2008 Nov;67(11):1574-7. Epub 2008 Jul 14.

Tight control and intensified COBRA combination treatment in early

rheumatoid arthritis: 90% remission in a pilot trial.

van Tuyl LH, Lems WF, Voskuyl AE, Kerstens PJ, Garnero P, Dijkmans BA, Boers M.

Department of Clinical Epidemiology & Biostatistics, VU University

Medical Center, Amsterdam, The Netherlands.

OBJECTIVE: To investigate the efficacy and feasibility of an intensive

combination treatment in early rheumatoid arthritis (RA) combined with

monitoring both disease activity and cartilage degradation.

METHODS: In a pilot trial, 21 patients with active early RA (mean

DAS28 5.3; mean disease duration 3 months) were treated with COBRA

treatment comprising sulfasalazine, methotrexate and high-dose

step-down prednisolone, intensified by adding hydroxychloroquine and

continued low-dose prednisolone. In addition, based on measurements of

disease activity or a marker of cartilage degradation (CTX-II),

treatment adjustments were possible with methotrexate intensification

after 8 or 21 weeks; and with infliximab after 21 weeks.

RESULTS: Nineteen of 21 patients (90%) were in remission (DAS28 <2.6)

after 40 weeks (8 weeks, 57%; 21 weeks, 76%). American College of

Rheumatology (ACR) criteria, ACR20, 50, 70 and 90 improvements rates

were 100%, 95%, 71% and 43% respectively. CTX-II excretion decreased

by mean (SD) 347(292) ng/mmol creatinine, but only 50% of patients

reduced their CTX-II excretion below the cut-off point. The two

monitoring groups showed no significant difference in remission

according to DAS score or CTX-II excretion, despite a trend towards

more intensive treatment in the CTX-II group. Treatment

intensification was feasible according to protocol.

CONCLUSIONS: This small pilot study suggests that intensified and

tightly controlled COBRA treatment is uniquely effective in early RA.

TRIAL REGISTRATION NUMBER: ISRCTN96372677.

PMID: 18625629

http://www.ncbi.nlm.nih.gov/pubmed/18625629

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