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The Effectiveness of Early Treatment with “Second-Line” Antirheumatic Drugs: A Randomized, Controlled Trial

Agnes van der Heide, MD; Johannes W.G. Jacobs, MD; Johannes W.J. Bijlsma, MD; Anton H.M. Heurkens, MD; Christina van Booma-Frankfort, MD; Maaike J. van der Veen, MD; Huub C.M. Haanen, MD; and Dick M. Hofman, MD
[+] Article and Author Information

For a listing of additional authors and current author addresses, see end of text. Acknowledgments: The authors thank A. Algra, M. Boers, C. Cornelis, O. Huber-Bruning, E. Oostveen, and P.L.C.M. van Riel for their contributions to this article. Grant Support: Grant VR/235 from the Dutch League against Rheumatism (Het Nationaal Reumafonds). Requests for Reprints: Johannes W.G. Jacobs, MD, Department of Rheumatology F02.223, University Hospital Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands. Current Author Addresses: Dr. van der Heide: Department of Public Health, Faculty of Medicine, Erasmus University, PO Box 1738, 3000 DR Rotterdam, the Netherlands.


Ann Intern Med. 1996;124(8):699-707. doi:10.7326/0003-4819-124-8-199604150-00001
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Objective: To compare two therapeutic strategies for patients with recent-onset rheumatoid arthritis.

Design: Open, randomized clinical trial.

Setting: Outpatient clinics of six clinical centers.

Patients: 238 consecutive patients with recently diagnosed rheumatoid arthritis.

Interventions: Delayed or immediate introduction of treatment with slow-acting antirheumatic drugs (SAARDs).

Measurements: Primary end points were functional disability, pain, joint score, and erythrocyte sedimentation rate at 6 and 12 months and progression of radiologic abnormalities at 12 months.

Results: Statistically significant advantages at 12 months for patients receiving the SAARD strategy (immediate treatment with SAARDs) with regard to all primary end points that may be clinically important are indicated by the differences in improvements from baseline and their 95% CIs. These differences were 0.3 (95% CI, 0.2 to 0.6) for disability (range, 0 to 3), 10 mm (CI, 1 to 19 mm) for pain (range, 0 to 100 mm), 39 (CI, 4 to 74) for joint score (range, 0 to 534), and 11 mm/h (CI, 3 to 19 mm/h) for erythrocyte sedimentation rate (range, 1 to 140 mm/h), all in favor of SAARD treatment. The SAARD strategy also appears to be advantageous at 6 months. Radiologic abnormalities progressed at an equal rate in the SAARD and the non-SAARD groups; the difference in progression (range, 0 to 448) was 1 (CI, − 3 to 5). Analyses were based on the intention-to-treat principle and thus included 29% of patients in the non-SAARD group who discontinued the non-SAARD treatment strategy; treatment was usually discontinued because of insufficient effectiveness. The SAARD strategy including two alternative SAARDs could not be continued by 8% of patients, usually because of adverse reactions.

Conclusions: Early introduction of SAARDs may be more beneficial than delayed introduction for patients with recently diagnosed rheumatoid arthritis.

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