Advanced Therapies Help Rheumatoid Arthritis

Combination therapies that include cutting-edge steroids or the latest biologic agents are effective against early stage rheumatoid arthritis (RA), according to a study reported in Arthritis and Rheumatism.

The combined therapy appears to more rapidly and effectively halt the crippling effects of early stage RA than conventional single-drug therapies do, the researchers say.

"Initial treatment with a combination of drugs results in an earlier regain of function, and less damage to the joints," says study author Dr. Y.P.M. Goekoop-Ruiterman, of Leiden University Medical Center in the Netherlands.

A Serious and Painful Disease

A chronic disease of the joints, RA often persists throughout the lifetime of a diagnosed patient, potentially inflicting long-term damage while causing extreme pain and a disabling loss of mobility.

According to the Arthritis Foundation (AF), more than 2 million Americans suffer from RA, which usually first strikes between the ages of 30 and 50.

Although 70 percent of RA patients are women, men are often seriously disabled by the disease.

Standard treatments have typically involved the initial use of a single disease-modifying, anti-rheumatic drug (DMARD) - perhaps later augmented with more DMARDs down the line.

Combination treatments involve the immediate multiple use of DMARDs alongside other medications such as the steroid prednisone or one of the newer biologic agents, such as infliximab (Remicade).

Biologic agents work by disabling the body's tumor necrosis factor alpha (TNF) protein, which is known to promote inflammation.

To identify the best treatment, Dr. Goekoop-Ruiterman and her colleagues offered the four most common treatment options to 508 early stage RA patients - mostly women - who lived in the Netherlands when they were diagnosed with the disease between 2000 and 2002.

Divided equally into four groups, the patients were all over the age of 18 and none had been diagnosed with the illness for more than two years or treated with DMARD medications before the study started.

The first group started treatment with a so-called "conventional" DMARD medication called methotrexate.

The second group also took methotrexate, but as part of a "step-combination therapy" that included the later addition of other DMARDs as well as prednisone.

The third group began a combination treatment that immediately included methotrexate, the DMARD medication sulphasalazine, and prednisone.

The fourth group was given what was described as "the most aggressive strategy" - methotrexate along with the TNF-blocking infliximab.

The study provided functional ability exams, blood tests, and X-rays of hand and feet joints.

These tests revealed that adverse side effects were similar across all groups, and that nearly one-third of all the patients had entered clinical remission from RA one year following the start of treatment.

However, Dr. Goekoop-Ruiterman found that patients included in the third and fourth treatment groups generally fared better than those in the other groups.

After one year, "low-disease activity" was observed in 71 percent and 74 percent of the third and fourth groups, respectively. This compared with 53 percent and 64 percent among the first and second groups, respectively.

After three months of treatment, the researchers found that functional and clinical improvements were occurring more rapidly among the third and fourth groups - an outcome that held, to a lesser degree, after a full year of treatment.

Also, more patients in the third and fourth groups showed either less progression or no progression of joint disease after one year than did patients who had been offered only one DMARD medication to start.

Refining Medication Regimen Key

Dr. Goekoop-Ruiterman concludes that, despite seemingly better success with more aggressive therapies, the treatment-option picture still remains cloudy.

She notes that starting with a single medication option, such as methotrexate, did seem to adequately control RA for more than 40 percent of the study patients.

This raised concerns that starting all patients on more aggressive combination treatments might, in fact, lead to overtreatment.

However, the researcher also points out that the faster relief of symptoms and physical function improvement among combination-therapy patients were significant advantages of aggressive treatments.

This approach might help prevent long-term joint damage by stopping the disease in its tracks at an earlier stage.

Dr. Stephen Lindsey, head of rheumatology at Ochsner Clinic Foundation Hospital in New Orleans, says patients should be evaluated on a case-by-case basis, for both medical and economic reasons.

"The trick is to establish which patients these combination drugs are best for, because the newer biologic drugs cost about $2,000 each month," he explains.

"So we need to tailor the more aggressive treatments to the people who need it, and not forget about the standard treatments, which many people do well on, which have less risk of infections because there's less immunosuppression, and which are less expensive," notes Dr. Lindsey.

Dr. Hayes Wilson, a rheumatologist and medical advisor for the AF, agrees that money is always an issue.

"In the real world, these biologic drugs are far more expensive than DMARDs, and it's an economic reality that there are patients who just can't afford it," comments Dr. Wilson. "Even for insurance companies, a diagnosis of rheumatoid arthritis is like a seven-alarm fire, because they know it's so expensive to treat."

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