How aggressive should initial therapy for rheumatoid arthritis be? The Finnish experience

K. Kaarela, M. Hakala, P. Hannonen1, H. Kautiainen, M. Korpela2, M. Leirisalo-Repo3, R. Luosujärvi4, R. Luukkainen5, T. Möttönen6 and K. Puolakka7

Rheumatism Foundation Hospital, Heinola, 1 Jyväskylä Central Hospital, Jyväskylä, 2 Tampere University Central Hospital, Tampere, 3 Helsinki University Central Hospital, Helsinki, 4 Kuopio University Central Hospital, Kuopio, 5 Satakunta Central Hospital, Rauma, 6 Turku University Central Hospital, Turku and 7 Lappeenranta Central Hospital, Lappeenranta, Finland

Correspondence to: K. Kaarela. E-mail: kalevi.kaarela{at}reuma.fi

SIR, We read with interest the report of Matteson et al. [1] concerning 2-yr results of hydroxychloroquine (HCQ) treatment in 111 patients with early rheumatoid arthritis (RA). After 2 yr of follow-up, inflammatory activity decreased statistically significantly, but the percentage of patients with erosions increased from 26% to 59%. At 2 yr the mean number of swollen joints was nine, and 38 patients (40% of 94 who completed 2 yr) did not apparently have an ACR50 response. Despite these findings, the authors suggest that treatment with HCQ is ‘greatly beneficial in patients with early RA’.

A Finnish cohort from Heinola was one of the first prospective cohorts of patients with recent-onset (<6 months) RA. One hundred and three RF-positive patients were enrolled in this cohort in 1973–1975. At the time of diagnosis, 31% of patients began HCQ, 51% gold sodium thiomalate, 5% a combination of these, and 2% penicillamine; 85% were taking these drugs at the 1-yr visit and 76% at the 3-yr visit [2]. However, these treatments did not prevent severe joint damage or amyloidosis in most patients over the subsequent 20 yr [2–4]. In fact, HCQ has never been shown to prevent erosions in RA [5].

In the Finnish Rheumatoid Arthritis Combination Therapy trial (FIN-RACo) study, 195 patients with early RA were randomized to receive a combination of methotrexate (MTX), sulphasalazine (SSZ), HCQ and prednisolone vs SSZ only (with or without prednisolone), which could be switched to MTX or to another single anti-rheumatic drug [6]. At the 2-yr visit, 75% of patients who received combinations and 58% of patients who received a single DMARD therapy had ACR50 responses. Furthermore, remission was observed in 37% and 18% respectively. The importance of early remission was emphasized with the observation that all patients who met remission criteria during the first 6 months continued working for 5 yr, in contrast to work disability in 22% of patients who met ACR20 or ACR50 responses [7]. Furthermore, 54% of patients who improved less than ACR20 became work-disabled over 5 yr, similar to higher rates of work disability in the past.

Long-term follow-up will reveal whether the Mayo clinic study [1] is one of those described by Verna Wright: ‘Clinicians may all too easily spend years writing ‘doing well’ in the notes of a patient who has become progressively more crippled before their eyes’ [8].

The authors have declared no conflicts of interest.

References

  1. Matteson EL, Weyand CM, Fulbright JW, Christianson TJH, McClelland RL, Goronzy JJ. How aggressive should initial therapy for rheumatoid arthritis be? Factors associated with response to ‘non-aggressive’ DMARD treatment and perspective from a 2-yr open label trial. Rheumatology 2004;43:619–25.[Abstract/Free Full Text]
  2. Jäntti JK, Kaarela K, Belt EA, Kautiainen HJ. Incidence of severe outcome in rheumatoid arthritis during 20 years. J Rheumatol 2002;29:688–92.[ISI][Medline]
  3. Kaarela K, Kautiainen H. Continuous progression of radiological destruction in seropositive rheumatoid arthritis. J Rheumatol 1997;24:1285–7.[ISI][Medline]
  4. Sokka T. Early rheumatoid arthritis in Finland. Clin Exp Rheumatol 2003;21:S133–7.
  5. Pincus T, Ferraccioli G, Sokka T et al. Evidence from clinical trials and long-term observational studies that disease-modifying anti-rheumatic drugs slow radiographic progression in rheumatoid arthritis: updating a 1983 review. Rheumatology 2002;41:1346–56.[Abstract/Free Full Text]
  6. Möttönen T, Hannonen P, Leirisalo-Repo M et al. Comparison of combination therapy with single-drug therapy in early rheumatoid arthritis: a randomised trial. FIN-RACo trial group. Lancet 1999;353:1568–73.[CrossRef][ISI][Medline]
  7. Puolakka K, Kautiainen H, Möttönen T, Hannonen P, Leirisalo-Repo M. Early control of disease activity maintains working capacity in early rheumatoid arthritis. Ann Rheum Dis 2004;63(Suppl. 1):56.
  8. Smith T. Questions on clinical trials. [Editorial]. Br Med J 1983;287:569.
Accepted 4 August 2004





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