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 19731975. 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 [24]. 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.
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