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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