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VBCR - February 2015, Volume 4, No 1 - In the Literature

Treating rheumatoid arthritis (RA) early in the course of the disease can lead to improved outcomes, according to a large study published online in Annals of Rheumatic Disease January 5, 2015. The study suggests that there is a window of opportunity within a few months of symptom onset when treatment with disease-modifying antirheumatic drugs (DMARDs) can have an impact on joint erosion and inflammation, possibly reducing the need for orthopedic surgery, noted lead author Jessica A.B. van Nies, MD, Leiden University Medical Center, the Netherlands, and colleagues.

In more than 1200 RA patients receiving DMARDs, the authors found that early treatment led to more durable DMARD-free remissions compared with delayed treatment.

Patients often wait to consult a doctor when they first have symptoms of RA, and the authors say that strategies are needed to get patients to treatment earlier so as to capitalize on this not-very-broad window of opportunity.

The study explored the association between treatment onset and DMARD-free remission (primary outcome measure) in patients in 2 longitudinal observation cohorts: 738 patients enrolled in the Leiden Early Arthritis Clinic (EAC) cohort and 553 patients enrolled in the Evaluation et Suivi de Polyarthrites Indifférenciées Recentes (ESPOIR) cohort in Nimes, France. Log-hazard ratios were used to evaluate the relationship between duration of symptoms before treatment and DMARD-free sustained remission in 5 years of follow-up.

At the time of enrollment in the cohort, median symptom duration was 18.7 weeks for EAC and 21.3 weeks for ESPOIR. Methotrexate was initiated in 76.3% of EAC patients and 67% of ESPOIR patients. The majority of the remaining patients in each cohort were started on either sulfasalazine or hydroxychloroquine.

Over 5 years of follow-up, 11.5% of EAC patients and 5.4% of ESPOIR patients enjoyed DMARD-free remissions. A nonlinear association was observed, with a decrease in DMARD-free sustained remission after about 15 to 19 weeks of symptom duration, suggesting that “a confined period in which the disease is more susceptible to treatment is present indeed,” the authors wrote.

The exact duration of that confined period was harder to pin down. Using time-dependent receiver-operated characteristic curves with DMARD-free sustained remission as the outcome, in both cohorts the area under the curve was relatively low, making it difficult to identify the optimum time window for initiation of treatment.

The 2 cohorts differed somewhat in this regard. For the EAC cohort, 14.9 weeks of symptom duration was able to discriminate between patients with DMARD-free remissions from those with persistent disease, whereas 19.1 weeks appeared to be the symptom duration that was most sensitive and specific in the ESPOIR cohort.

The authors did not suggest that treating after this “window of opportunity” is not effective but rather that treating early might lead to a better outcome. Patients who are diagnosed with RA after 15 or 20 weeks of persistent symptoms should definitely be treated, they wrote.

van Nies JA, et al. Ann Rheum Dis. Published online: January 5, 2015.

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Last modified: May 21, 2015
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