What Is the Best Pharmacologic Approach for Early RA?
What Is the Best Pharmacologic Approach for Early RA?
O'Dell JR, Curtis JR, Mikuls TR, et al; TEAR Trial Investigators
Arthritis Rheum. 2013;65:1985-1994
The American College of Rheumatology guidelines for the treatment of rheumatoid arthritis (RA), updated in 2012, suggest initiating treatment as early as possible and preferably within 6 months of disease onset. Moreover, these guidelines recommend the use of combination therapy in early RA (< 6 months) if the patient presents with poor prognostic features, such as functional limitations, erosions, extra-articular disease, and elevations of autoantibodies.
However, some studies suggest that a substantial proportion of patients with RA will do well with methotrexate (MTX) monotherapy. Therefore, it is still controversial what the initial therapy should be in RA, and especially in early disease.
O'Dell and colleagues addressed this question through a post hoc analysis of results from the Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial, which were originally published in 2012. Specifically, they evaluated outcomes in patients with early (the mean RA duration in all patients was 3.6 months); active (> 4 swollen and 4 tender joints); and "poor prognosis" RA, which was defined by autoantibody positivity (rheumatoid factor or citric citrullinated peptide) or at least 2 erosions on radiographs of the hands, wrists, or feet. Moreover, patients could not have previously used biologics or have had a corticosteroid injection within 4 weeks before the study.
Patients were initially randomly assigned to 3 groups: MTX monotherapy, MTX plus etanercept, or MTX plus hydroxychloroquine and sulfasalazine. All patients received oral MTX beginning at 10 mg/week and, depending on disease activity, escalating to 20 mg/week by week 12. Patients could be "stepped up" from MTX monotherapy to combination therapy if the Disease Activity Score-28 using erythrocyte sedimentation rate (DAS28ESR) was 3.2 or greater at 24 weeks. Stable doses of prednisone ≤ 10 mg/day and nonsteroidal drugs were allowed. The mean DAS28ESR at baseline in all patients in the parent trial was 5.8.
Validation of the Methotrexate-First Strategy in Patients With Early, Poor-Prognosis Rheumatoid Arthritis: Results From a Two-Year Randomized, Double-blind Trial
O'Dell JR, Curtis JR, Mikuls TR, et al; TEAR Trial Investigators
Arthritis Rheum. 2013;65:1985-1994
Early Treatment of Rheumatoid Arthritis
The American College of Rheumatology guidelines for the treatment of rheumatoid arthritis (RA), updated in 2012, suggest initiating treatment as early as possible and preferably within 6 months of disease onset. Moreover, these guidelines recommend the use of combination therapy in early RA (< 6 months) if the patient presents with poor prognostic features, such as functional limitations, erosions, extra-articular disease, and elevations of autoantibodies.
However, some studies suggest that a substantial proportion of patients with RA will do well with methotrexate (MTX) monotherapy. Therefore, it is still controversial what the initial therapy should be in RA, and especially in early disease.
Study Summary
O'Dell and colleagues addressed this question through a post hoc analysis of results from the Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial, which were originally published in 2012. Specifically, they evaluated outcomes in patients with early (the mean RA duration in all patients was 3.6 months); active (> 4 swollen and 4 tender joints); and "poor prognosis" RA, which was defined by autoantibody positivity (rheumatoid factor or citric citrullinated peptide) or at least 2 erosions on radiographs of the hands, wrists, or feet. Moreover, patients could not have previously used biologics or have had a corticosteroid injection within 4 weeks before the study.
Patients were initially randomly assigned to 3 groups: MTX monotherapy, MTX plus etanercept, or MTX plus hydroxychloroquine and sulfasalazine. All patients received oral MTX beginning at 10 mg/week and, depending on disease activity, escalating to 20 mg/week by week 12. Patients could be "stepped up" from MTX monotherapy to combination therapy if the Disease Activity Score-28 using erythrocyte sedimentation rate (DAS28ESR) was 3.2 or greater at 24 weeks. Stable doses of prednisone ≤ 10 mg/day and nonsteroidal drugs were allowed. The mean DAS28ESR at baseline in all patients in the parent trial was 5.8.
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