Early Treatment Optimal for Slowing Rheumatoid Arthritis Progression

There is an early period in rheumatoid arthritis (RA) progression where the disease is more susceptible to treatment, according to findings published in the Annals of Rheumatic Diseases.

Researchers from the Netherlands and France examined about 1200 RA patients who were treated with disease modifying anti rheumatic drugs (DMARDs) in various clinics in order to evaluate the shape of the association of symptom duration with the persistence of RA. There were 738 patients recruited from the Leiden Early Arthritis Clinic (EAC) and 533 patients came from the Evaluation et Suivi de POlyarthrites Indifférenciées Récentes (ESPOIR). The researchers hypothesized there would be a window of opportunity when the disease was more susceptible to treatment.

After the follow up period of 5 years, 11.5 percent of EAC patients and 5.4 percent of the ESPOIR patient had DMARD free sustained remissions. In the EAC cohort, the DMARD free remission period was about 14.9 weeks. For the ESPOIR patient group, the DMRAD free remission period was about 19.1 weeks. The curves plotted for both groups began to flatten out near the 15 to 20 week point after the onset of RA symptoms.

However, the confined period of time when DMARD free remission was possible was less clear to the researchers. After analysis, the authors acknowledged the optimum time frame for starting treatment was unclear.

“It cannot be concluded that the window ‘is closed’ after this period, but the data of the present cohorts clearly showed that the hazard on remission was less after this period, and so possibly it ‘starts to close’ at this point in time,” the authors wrote. “In other words, we do not suggest that DMARD treatment after a certain window is futile, but that initiating a DMARD in this particular window might yield a better outcome. In case a patient is identified after this period has passed, DMARD therapy should certainly not be withheld.”

The authors recognized other literature about similar studies, which mention worse outcomes — such as more severe joint destruction, more orthopedic surgeries, lower likelihood of having a DMARD free sustained remission, and a higher RA related mortality – for RA patients with long disease or symptom duration before they are started on DMARDs.

“This study is the first providing strongly suggestive evidence that a confined period in which RA is more susceptible to treatment [exists],” the authors concluded. “Further proof might be obtained by performing clinical trials in patients with symptoms of very recent onset randomizing for direct or delayed treatment. However, given the present knowledge this may be considered unethical.”