Intensive initial therapy with triple DMARDs improves functional ability in early rheumatoid arthritis

"Many trials have shown that early and intensive treatment can induce remission and prevent joint damage in patients with rheumatoid arthritis, yet often a step-wise approach of escalating treatment is preferred," said lead author Dr. Angelique Weel of the Department of Rheumatology, Maasstad Hospital, Netherlands. "Our data showed an earlier decrease in disease severity and improvements in functional ability in the combination-therapy groups compared to monotherapy, adding to the evidence base for an intensive treatment approach early on. And with significant numbers of patients achieving drug-free remission using less expensive biologicals during the first two years of therapy, these data should alleviate concerns regarding the need for long-term aggressive therapy."

Functional ability was measured using the Health Assessment Questionnaire (HAQ), a good predictor of future disability and cost. After just three months, improvements in HAQ score were significantly greater in the triple DMARD induction therapy group, and remained significant throughout the two years, irrespective of disease activity. Joint damage progression seen on X-rays was minimal and similar for both groups.

281 RA patients were randomised to methotrexate, sulfasalazine and hydroxychloroquine with bridging glucocorticoid or methotrexate alone (with glucocorticoid). After two years, the percentage of patients attaining a DAS44 score (composite score of disease activity) less than 1.6 at two consecutive time points (sustained remission) was similar for those patients started on triple DMARD therapy (51%) vs. monotherapy (47%). Exacerbation of symptoms (prevalence of flares) after tapering medication was similar between the combination and monotherapy groups.