All this talk about biologics could lead you to believe that is the only way...but this pilot study shows that combination DMARDs remain a rational first choice for many patients.

 

 

Published Online First: 14 July 2008. doi:10.1136/ard.2008.090712
Annals of the Rheumatic Diseases 2008;67:1574-1577
Copyright © 2008 BMJ Publishing Group Ltd & European League Against Rheumatism

CLINICAL AND EPIDEMIOLOGICAL RESEARCH

Tight control and intensified COBRA combination treatment in early rheumatoid arthritis: 90% remission in a pilot trial

L H D van Tuyl ¹, W F Lems ², A E Voskuyl ², P J S M Kerstens ³, P Garnero ⁴, B A C Dijkmans ², M Boers ⁵

¹ Department of Clinical Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
² Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
³ Jan van Breemen Institute, Amsterdam, The Netherlands
⁴ INSERM Unit 664 and Synarc, Lyon, France
⁵ VU University Medical Center, Clinical Epidemiology & Biostatistics, Amsterdam, The Netherlands

 

Correspondence to:
Lilian H D van Tuyl, VU University Medical Center, Department of Clinical Epidemiology & Biostatistics, PK 6Z 159, PO Box 7057, 1007 MB Amsterdam, The Netherlands; L.vantuyl@vumc.nl

Objective: To investigate the efficacy and feasibility of an intensive combination treatment in early rheumatoid arthritis (RA) combined with monitoring both disease activity and cartilage degradation.

Methods: In a pilot trial, 21 patients with active early RA (mean DAS28 5.3; mean disease duration 3 months) were treated with COBRA treatment comprising sulfasalazine, methotrexate and high-dose step-down prednisolone, intensified by adding hydroxychloroquine and continued low-dose prednisolone. In addition, based on measurements of disease activity or a marker of cartilage degradation (CTX-II), treatment adjustments were possible with methotrexate intensification after 8 or 21 weeks; and with infliximab after 21 weeks.

Results: Nineteen of 21 patients (90%) were in remission (DAS28 <2.6) after 40 weeks (8 weeks, 57%; 21 weeks, 76%). American College of Rheumatology (ACR) criteria, ACR20, 50, 70 and 90 improvements rates were 100%, 95%, 71% and 43% respectively. CTX-II excretion decreased by mean (SD) 347(292) ng/mmol creatinine, but only 50% of patients reduced their CTX-II excretion below the cut-off point. The two monitoring groups showed no significant difference in remission according to DAS score or CTX-II excretion, despite a trend towards more intensive treatment in the CTX-II group. Treatment intensification was feasible according to protocol.

Conclusions: This small pilot study suggests that intensified and tightly controlled COBRA treatment is uniquely effective in early RA.

Trial registration number: ISRCTN96372677.