Early therapy is nothing new in rheumatoid arthritis

J. R. Kirwan

Division of Medicine, Bristol Royal Infirmary, Bristol BS2 8HW, UK

SIR, It has become fashionable to urge that rheumatologists of today, unlike their predecessors, should treat rheumatoid arthritis (RA) patients with second-line (‘disease-modifying’) therapy ‘early’ in their disease. This view is based on the assumption that patients have traditionally been treated late in their disease. I collect trials of second-line therapy in RA, and I did not recognize a history of such tardiness in initiating treatment, either from my reading or from my recollection of clinical practice 20 yr ago. I therefore reviewed a random selection of the studies of second-line therapy in RA in my collection, and extracted the date of the study, the mean disease duration of those included in treatment, and the range of disease duration. The results are shown in Fig. 1Go.



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FIG. 1 Mean (range) patient disease duration in 30 randomized controlled trials of second-line therapy in RA.

 
It can be seen that rheumatologists have included patients with early disease (less than, say, 5 yr of disease duration) ever since randomized controlled trials were begun in RA. Indeed, where it was possible to extract the range of disease duration there were nearly always patients included who had less than 1 yr of disease. The average disease duration for all trials taken together was 5.7 yr.

Thus, urging early treatment in RA is superfluously preaching to the converted. I am not aware of any substantial change in my own practice, yet in a recent survey of patients in my clinic, 75% of those within 2 yr of disease onset were already taking second-line treatment.

Accepted 27 June 2000





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