OBJECTIVES: Targeted treatment is effective in the short term in achieving low disease activity or even remission in patients with rheumatoid arthritis (RA). The benefits of long-term targeted... Show moreOBJECTIVES: Targeted treatment is effective in the short term in achieving low disease activity or even remission in patients with rheumatoid arthritis (RA). The benefits of long-term targeted treatment are discussed based on the BeSt study results. METHODS: The BeSt study has incorporated 7 years of targeted treatment, aiming at low disease activity (DAS =<2.4), and including both treatment intensification when DAS is high and treatment tapering and discontinuation if DAS is persistently low. Functional ability over time, (drug free) remission percentages, treatment adjustments and radiological outcomes over 7 years are discussed. RESULTS: Targeted treatment resulted in stabilisation of functional ability after initial improvement, minimal radiological damage progression after the first year, and tapering of medication. Drug free remission was achieved in 15% of completers in year 7. Patients who lost drug free remission (46% up to year 5) restarted treatment and mostly regained remission without radiological deterioration. Patients treated with initial combination therapy responded earlier and had less damage progression that remained evident up to five years follow up. CONCLUSIONS: Early and maintained targeted treatment has functional and radiological benefits over the first 7 years of the BeSt study and can include drug tapering and (partial, temporary or permanent) discontinuation. Show less
After achieving low disease activity or remission, biological therapy might be stopped in rheumatoid arthritis patients, but information on whether and how this should be done is scarce. Successful... Show moreAfter achieving low disease activity or remission, biological therapy might be stopped in rheumatoid arthritis patients, but information on whether and how this should be done is scarce. Successful discontinuation was highly variable since it was described in 0-97% of patients, in studies with different patient populations and follow-up durations between 12 weeks and over 7 years. In most studies, patients were required to have low disease activity or be in clinical remission for at least 6 months before biological therapy was discontinued. Significant joint damage progression in the first year after discontinuation was rare and functional ability was relatively stable in almost all patients in this year. In patients who had a disease flare, retreatment with biological therapy was successful in 70-100%. Mild infusion reactions after retreatment were described in a small number of patients. In conclusion, in the absence of a guideline for stopping biologicals in RA, we present a preliminary proposal that biological therapy can be stopped in many RA-patients after achieving low disease activity or remission for at least 6 months. Adequate monitoring of disease activity is essential, and retreatment appears to be safe and successful in many patients. Future research may further identify when and/or which patients are most likely to discontinue biological treatment successfully. Show less
Broek, M. van den; Dirven, L.; Vries-Bouwstra, J.K. de; Dehpoor, A.J.; Goekoop-Ruiterman, Y.P.M.; Gerards, A.H.; ... ; Allaart, C.F. 2012
Objective. To determine the prevalence of large-joint damage and the association with small-joint damage in patients with RA after 8 years of low DAS (≤2.4)-targeted treatment with different... Show moreObjective. To determine the prevalence of large-joint damage and the association with small-joint damage in patients with RA after 8 years of low DAS (≤2.4)-targeted treatment with different treatment strategies.Methods. Radiological data of 290 patients participating in the BeSt study, a randomized trial comparing initial monotherapy and initial combination therapy strategies, were used. Radiographs of large joints were scored using the Larsen score and of the small joints using the Sharp-van der Heijde score. With multivariate logistic regression analysis, an association between total damage of the small joints and of the large joints was investigated.Results. After 8 years of treatment, damage was observed in 12% of shoulders, 10% of elbows, 26% of wrists, 13% of hips, 18% of knees and 7% of the ankles. Damage in one or more large joints was found in 64% of patients, with a median score of 1. No difference was found between initial monotherapy or combination therapy strategies. There was a significant association between damage progression in small joints and damage to one or more large joints (OR 1.02; 95% CI 1.00-1.04).Conclusion. After 8 years of DAS-targeted treatment in early RA patients, large-joint damage was found in 64% of patients and was associated with small-joint damage. Continued DAS-targeted treatment is probably more important in damage suppression than initial treatment strategy. Patients with more damage to hands and feet also have more damage to the large joints. Show less
OBJECTIVE: Anticitrullinated protein antibodies (ACPAs) are suggested to identify different subsets of patients with rheumatoid arthritis (RA). The authors compared the clinical and radiological... Show moreOBJECTIVE: Anticitrullinated protein antibodies (ACPAs) are suggested to identify different subsets of patients with rheumatoid arthritis (RA). The authors compared the clinical and radiological responses to Disease Activity Score (DAS)-steered treatment in patients with RA positive or RA negative for ACPA.METHODS: In the BehandelStrategieën (BeSt) study, 508 patients with recent-onset RA were randomised to four treatment strategies aimed at a DAS ≤2.4. Risks of damage progression and (drug-free) remission in 8 years were compared for ACPA-positive and ACPA-negative patients using logistic regression analysis. Functional ability and DAS components over time were compared using linear mixed models.RESULTS: DAS reduction was achieved similarly in ACPA-positive and ACPA-negative patients in all treatment strategy groups, with a similar need to adjust treatment because of inadequate response. Functional ability and remission rates were not different for ACPA-positive and ACPA-negative patients. ACPA-positive patients had more radiological damage progression, especially after initial monotherapy. They had a lower chance of achieving (persistent) drug-free remission.CONCLUSION: Clinical response to treatment was similar in ACPA-positive and ACPA-negative patients. However, more ACPA-positive patients, especially those treated with initial monotherapy, had significant radiological damage progression, indicating that methotrexate monotherapy and DAS- (≤2.4) steered treatment might be insufficient to adequately suppress joint damage progression in these patients. Show less
Broek, M. van den; Dirven, L.; Kroon, H.M.; Oosterhout, M. van; Han, K.H.; Kerstens, P.J.S.M.; ... ; Allaart, C.F. 2011
