RESEARCH - 5-year outcomes of goal-steered treatment: BeSt

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Ann Rheum Dis doi:10.1136/ard.2010.141234

Clinical and epidemiological research

Extended report

The impact of four dynamic, goal-steered treatment strategies on the

5-year outcomes of rheumatoid arthritis patients in the BeSt study

Naomi B Klarenbeek1, Melek Güler-Yüksel1, Sjoerd M van der Kooij1, K

Huub Han2, H Karel Ronday3, Pit J S M Kerstens4, E H Seys5,

Tom W J Huizinga1, Ben A C Dijkmans4,6, Cornelia F Allaart1

1Department of Rheumatology, Leiden University Medical Center, Leiden,

The Netherlands

2Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands

3Department of Rheumatology, Haga Hospital, The Hague, The Netherlands

4Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The

Netherlands

5Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands

6Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands

Abstract

Objective To compare clinical and radiological outcomes of four

dynamic treatment strategies in recent-onset rheumatoid arthritis (RA)

after 5 years follow-up.

Methods 508 patients with recent-onset RA were randomly assigned into

four treatment strategies: sequential monotherapy; step-up combination

therapy; initial combination with prednisone; initial combination with

infliximab. Treatment adjustments were made based on 3-monthly disease

activity score (DAS) measurements (if DAS >2.4 next treatment step; if

DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS <1.6

during ≥6 months stop antirheumatic treatment). Primary and secondary

outcomes were functional ability, joint damage progression,

health-related quality of life and (drug-free) remission percentages.

Results After 5 years, 48% of patients were in clinical remission (DAS

<1.6) and 14% in drug-free remission, irrespective of initial

treatment. After an earlier improvement in functional ability and

quality of life with initial combination therapy, from 1 year onwards

clinical outcomes were comparable across the groups and stable during

5 years. The initial combination groups showed less joint damage in

year 1. In years 2–5 annual progression was comparable across the

groups. After 5 years, initial combination therapy resulted in

significantly less joint damage progression, reflecting the earlier

clinical response.

Conclusion Irrespective of initial treatment, an impressive

improvement in clinical and radiological outcomes of RA patients can

be achieved with dynamic treatment aimed at reducing disease activity,

leading to 48% remission, 14% drug-free remission and sustained

functional improvement. Starting with combination therapy resulted in

earlier clinical improvement and less joint damage without more

toxicity.

http://ard.bmj.com/content/early/2011/03/17/ard.2010.141234.abstract?papetoc

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