Highlights From EULAR 2008, The Annual European Congress Of Rheumatology

Half of patients with early rheumatoid arthritis treated with the anti-tumour necrosis factor inhibitor (anti-TNF) infliximab plus methotrexate achieve remission, and up to one in five achieve drug-free remission, according to five-year follow-up results from the BeSt study.


Patients treated initially with a combination of infliximab plus methotrexate achieved significantly better functional ability than those given other treatment regimens.


The Dutch BeSt (Behandel Strategie?«n) study randomised 508 patients with recent-onset rheumatoid arthritis to one of the four most frequently used treatment strategies:


1. Sequential monotherapy - starting with one drug, then trying other types of drug on their own


2. Step-up combination therapy - starting with one drug, then adding on a second, and third or fourth drug


3. Initial combination including tapered high-dose prednisone


4. Initial combination therapy with infliximab plus methotrexate


The patients were monitored intensively and their treatment adjusted to keep their disease activity score (DAS) low (i.e. below 2.4).


At the end of five years, 51% of patients treated with initial combination therapy with infliximab plus methotrexate and a similar number of those give sequential monotherapy were in remission (Disease Activity Score < 1.6), compared to 45% of those treated with step-up combination therapy and 42% of patients treatment with initial combination including prednisone.


Of these remissions, 39%, 46%, 65% and 81% was achieved with the initial treatment step in treatments groups 1 to 4 respectively (p







Reporting the findings at EULAR, Dr Naomi Klarenbeek, also from Leiden University, said: "Over time, patients treated with an initial combination of infliximab plus methotrexate have significantly better functional ability than patients on other treatment strategies."


Dr Andrew Ost?¶r, consultant rheumatologist at Addenbrooke's Hospital, Cambridge, UK, commented: "Patients with aggressive early rheumatoid arthritis potentially do better when treated with initial combination therapy including a biologic. They clearly improved more rapidly than patients treated with sequential monotherapy or step-up combination therapy. Early improvement is important for patients' confidence in their treatment." He added: "Continuous monitoring and tight disease control - based on DAS score - is important in optimising therapy for individual patients."1


Infliximab better than DMARDs in RA patients failing on methotrexate



Adding infliximab achieves significantly better response than adding the conventional disease modifying antirheumatic drugs (DMARDs) sulfasalazine plus hydroxychloroquine in patients with early rheumatoid arthritis failing initial methotrexate monotherapy, a Swedish study has shown.


The SWEFOT trial was designed to compare two strategies in patients with early RA who had failed an initial 3-4 months treatment with methotrexate monotherapy. Researchers initially treated 487 patients with early RA, with symptoms for less than one year, with methotrexate (up to 20mg/week).


After three to four months, the 258 patients who had not achieved remission (defined as DAS28 < 3.2) and who were unable to tolerate methotrexate were randomised to DMARD therapy with sulfasalazine plus hydroxychloroquine or to infliximab (3mg/kg/infusion, given at 0, 2, 6 weeks, then every 8 weeks). Patients were allowed to switch therapy once (to cyclosporine in the DMARD group and to etanercept in the anti-TNF group) if they were unable to tolerate their treatment.


Results reported at EULAR showed that just over one-quarter (26%) of patients treated with DMARD therapy achieved a EULAR good response after 12 months, compared to 42% of those treated with infliximab (p