REVIEW - The BeSt story: on strategy trials in RA

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Curr Opin Rheumatol. 2009 Mar 21.

The BeSt story: on strategy trials in rheumatoid arthritis.

Klarenbeek NB, Allaart CF, Kerstens PJ, Huizinga TW, Dijkmans BA.

aDepartment of Rheumatology, Leiden University Medical Center, Leiden,

The Netherlands bDepartment of Rheumatology, Jan van Breemen

Institute, The Netherlands cDepartment of Rheumatology, VU Medical

Center, Amsterdam, The Netherlands.

PURPOSE OF REVIEW: To give an overview of recent strategy trials for

the treatment of rheumatoid arthritis.

RECENT FINDINGS: Strategy studies showed a clear benefit of dynamic

result-driven treatment towards tight control of disease activity

compared with 'usual care' in rheumatoid arthritis patients. In

addition, treatment given after short symptom duration gives better

outcomes than later initiation of treatment. In many trials,

combination therapies, especially combinations with prednisolone or

biologicals, were superior to monotherapies. Moreover, combination

therapies were more effective if given early in the disease as

compared with a delayed introduction, giving support to the window of

opportunity hypothesis. In the BeSt study, initial combination therapy

could be successfully discontinued in half of the patients,

emphasizing that 'initial' would mean 'temporary'. Less evidence is

available about initial combination in comparison with combination

therapy with a shorter delay. Larger tight-controlled, goal-steered,

dynamic strategy trials comparing initial combination therapy with a

short-delay combination therapy will help to translate the use of

initial (temporary) combination therapy into normal daily practice.

SUMMARY: Treatment strategy trials have demonstrated that in the

majority of patients with rheumatoid arthritis, the following approach

is the most beneficial: goal-steered, dynamic treatment towards tight

control of disease activity, including early introduction of (an)

effective disease-modifying antirheumatic drug(s) in combination with

prednisone or antitumor necrosis factor, which includes tapering of

the medication if remission or low disease activity is achieved.

PMID: 19318946

http://www.ncbi.nlm.nih.gov/pubmed/19318946

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