Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early rheumatoid arthritis

ObjectivesTo compare the efficacy and safety of intensive combination strategies with glucocorticoids (GCs) in the first 16 weeks (W) of early rheumatoid arthritis (eRA) treatment, focusing on high-risk patients, in the Care in early RA trial.Methods400 disease-modifying antirheumatic drugs (DMARD)-naive patients with eRA were recruited and stratified into high risk or low risk according to classical prognostic markers. High-risk patients (n=290) were randomised to 1/3 treatment strategies: combination therapy for early rheumatoid arthritis (COBRA) Classic (methotrexate (MTX)+ sulfasalazine+60 mg prednisone tapered to 7.5 mg daily from W7), COBRA Slim (MTX+30 mg prednisone tapered to 5 mg from W6) and COBRA Avant-Garde (MTX+leflunomide+30 mg prednisone tapered to 5 mg from W6). Treatment modifications to target low-disease activity were mandatory from W8, if desirable and feasible according to the rheumatologist. The primary outcome was remission (28 joint disease activity score calculated with C-reactive protein <2.6) at W16 (intention-to-treat analysis). Secondary endpoints were good European League Against Rheumatism response, clinically meaningful health assessment questionnaire (HAQ) response and HAQ equal to zero. Adverse events (AEs) were registered.ResultsData from 98 Classic, 98 Slim and 94 Avant-Garde patients were analysed. At W16, remission was reached in 70.4% Classic, 73.6% Slim and 68.1% Avant-Garde patients (p=0.713). Likewise, no significant differences were shown in other secondary endpoints. However, therapy-related AEs were reported in 61.2% of Classic, in 46.9% of Slim and in 69.1% of Avant-Garde patients (p=0.006).ConclusionsFor high-risk eRA, MTX associated with a moderate step-down dose of GCs was as effective in inducing remission at W16 as DMARD combination therapies with moderate or high step-down GC doses and it showed a more favourable short-term safety profile.EudraCT number:2008-007225-39.

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THU0144 Two Year Radiological Follow-Up of Early Rheumatoid Arthritis Patients Treated with Initial Step Up Monotherapy or Initial Step Down Therapy with Glucocorticoids, Followed by a Tight Control Approach

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2013-eular.672 ◽

2013 ◽

Vol 72 (Suppl 3) ◽

pp. A211.3-A212 ◽

Cited By ~ 1

Author(s):

D. De Cock ◽

S. Meyfroidt ◽

G. Vanderschueren ◽

L. Lateur ◽

J. Joly ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Early Rheumatoid Arthritis ◽

Initial Step ◽

Tight Control ◽

Control Approach ◽

Step Down

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EFFICACY OF LEFLUNOMIDE ADDITION IN RELATION TO PROGNOSTIC FACTORS FOR PATIENTS WITH ACTIVE EARLY RHEUMATOID ARTHRITIS FAILING TO METHOTREXATE IN DAILY PRACTICE

European Journal of Internal Medicine ◽

10.1016/s0953-6205(11)60344-0 ◽

2011 ◽

Vol 22 ◽

pp. S84

Author(s):

Grigorios Sakellariou ◽

Charalampos Berberidis

Keyword(s):

Rheumatoid Arthritis ◽

Prognostic Factors ◽

Early Rheumatoid Arthritis ◽

Daily Practice

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The Gap Between Practice and Guidelines in the Choice of First-line Disease Modifying Antirheumatic Drug in Early Rheumatoid Arthritis: Results from the ESPOIR Cohort

The Journal of Rheumatology ◽

10.3899/jrheum.080762 ◽

2009 ◽

Vol 36 (5) ◽

pp. 934-942 ◽

Cited By ~ 22

Author(s):

MATHILDE BENHAMOU ◽

NATHALIE RINCHEVAL ◽

CARINE ROY ◽

VIOLAINE FOLTZ ◽

SYLVIE ROZENBERG ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Early Rheumatoid Arthritis ◽

Daily Practice ◽

Antirheumatic Drug ◽

First Line ◽

Diagnostic Uncertainty ◽

Early Ra ◽

Diagnostic Certainty ◽

Disease Modifying ◽

Disease Modifying Antirheumatic Drug

Objective.To compare rheumatologists’ prescription for first disease modifying antirheumatic drug (DMARD) in early rheumatoid arthritis (RA) in real-life settings with 2 clinical practice guidelines (CPG), the French Society of Rheumatology/STPR 2004 and EULAR/ESCISIT 2007, and thus assess the gap between practices and guidelines.Method.ESPOIR was a French multicenter cohort study of 813 patients with early arthritis between 2002 and 2005. “Definite” and “probable” RA were defined according to ACR criteria and the level of diagnostic certainty. The objectives were to assess conformity between the observed first-line DMARD prescribed for those patients and the DMARD recommended in the guidelines; and to conduct a mail survey of patients’ usual rheumatologists to investigate the reasons for their nonconformity with guidelines.Results.In total 627 patients with definite or probable RA were identified. Conformity rates were 58% for STPR guidelines and 54% for EULAR guidelines. At 6 months, 83 (34%) patients with early RA did not receive any DMARD. Main determinants associated with conformity to guidelines were disease activity and presence of severity-predictive factors. The main reason leading to a discrepancy between guidelines and daily practice appeared to be diagnostic uncertainty, i.e., the difficulty to reliably assess RA diagnosis as early as the first visits to the rheumatologist.Conclusion.There is a substantial gap between CPG and rheumatologists’ daily practice concerning the first DMARD to prescribe in early RA. This is explained mainly by diagnostic uncertainty. More attention should be paid in future guidelines to the diagnostic difficulties of early RA.

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Is a step-down regimen more effective than a step-up regimen in the treatment of early rheumatoid arthritis?

Nature Clinical Practice Rheumatology ◽

10.1038/ncprheum0861 ◽

2008 ◽

Vol 4 (8) ◽

pp. 396-397

Author(s):

Edward C Keystone

Keyword(s):

Rheumatoid Arthritis ◽

Early Rheumatoid Arthritis ◽

Step Down

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Faculty Opinions recommendation of Patients lacking classical poor prognostic markers might also benefit from a step-down glucocorticoid bridging scheme in early rheumatoid arthritis: week 16 results from the randomized multicenter CareRA trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725440853.793521884 ◽

2016 ◽

Author(s):

David Scott

Keyword(s):

Rheumatoid Arthritis ◽

Early Rheumatoid Arthritis ◽

Prognostic Markers ◽

Step Down

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Step-down approach using either cyclosporin A or methotrexate as maintenance therapy in early rheumatoid arthritis

Arthritis & Rheumatism ◽

10.1002/art1.10245 ◽

2002 ◽

Vol 47 (1) ◽

pp. 59-66 ◽

Cited By ~ 9

Author(s):

Antonio Marchesoni ◽

Norma Battafarano ◽

Marco Arreghini ◽

Raffaele Pellerito ◽

Maria Cagnoli ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Maintenance Therapy ◽

Cyclosporin A ◽

Early Rheumatoid Arthritis ◽

Step Down

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Five-year Favorable Outcome of Patients with Early Rheumatoid Arthritis in the 2000s: Data from the ESPOIR Cohort

The Journal of Rheumatology ◽

10.3899/jrheum.121515 ◽

2013 ◽

Vol 40 (10) ◽

pp. 1650-1657 ◽

Cited By ~ 26

Author(s):

Bernard Combe ◽

Nathalie Rincheval ◽

Joelle Benessiano ◽

Francis Berenbaum ◽

Alain Cantagrel ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Disease Activity ◽

Early Rheumatoid Arthritis ◽

Radiographic Progression ◽

Health Assessment ◽

Daily Practice ◽

Joint Disease ◽

Early Ra ◽

American College Of Rheumatology ◽

Biologic Dmard

Objective.To report the 5-year outcome of a large prospective cohort of patients with very early rheumatoid arthritis (RA), and to identify factors predictive of outcome.Methods.Patients were recruited if they had early arthritis of < 6 months’ duration, had a high probability of developing RA, and had never been prescribed disease-modifying antirheumatic drugs (DMARD) or steroids. Logistic regression analysis was used to determine factors that predict outcome.Results.We included 813 patients from December 2002 to April 2005. Age was 48.1 ± 12.6 years, delay before referral 103.1 ± 52.4 days, 28-joint Disease Activity Score (DAS28) 5.1 ± 1.3, Health Assessment Questionnaire (HAQ) 1.0 ± 0.7; 45.8% and 38.7% had rheumatoid factor or antibodies to cyclic citrullinated peptide (anti-CCP), respectively; 22% had hand or foot erosions; 78.5% fulfilled the American College of Rheumatology/European League Against Rheumatism criteria for RA at baseline and 93.8% during followup. At 5 years, 573 patients were evaluated. The outcome was mild for most patients: disease activity (median DAS28 = 2.5) and HAQ disability (median 0.3) were well controlled over time; 50.6% achieved DAS28 remission and 64.7% low disease activity. Radiographic progression was low (2.9 Sharp unit/year) and only a few patients required joint surgery. Nevertheless, some patients developed new comorbidities. During the 5 years, 82.7% of patients had received at least 1 DMARD (methotrexate, 65.9%), 18.3% a biological DMARD, and about 60% prednisone at least once. Anti-CCP was the best predictor of remaining in the cohort for 5 years, of prescription of synthetic or biologic DMARD, and of radiographic progression.Conclusion.The 5-year outcome of an early RA cohort in the 2000s was described. Anti-CCP was a robust predictor of outcome. The generally good 5-year outcome could be related to early referral and early effective treatment, key processes in the management of early RA in daily practice.

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