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The Importance of Early Intervention in the Treatment of Rheumatoid Arthritis

March 27, 2002

Study Indicates that Even a Few Months Delay in Implementing Drug Therapy Increases Long-Term Disease Severity and Joint Damage      

Findings Underscore the Urgency for Rapid Access of Patients to Specialist Care

In a recent study, researchers found that the delay of treatment to patients with early Rheumatoid Arthritis (RA) significantly decreases the ability of traditional single-drug therapy to combat the disease`s debilitating symptoms. According to the study, which is published in the April 2002 issue of Arthritis & Rheumatism, a single-drug strategy is insufficient to achieve remission and prevent joint damage unless initiated at the onset of RA symptoms.

"Spontaneous remissions are rare in established RA and, most cases, the disease shows a resistant course with progressive joint damage and increasing disability," observes chief researcher Timo Möttönen, M.D., Ph.D., the Head of the Division of Rheumatology at Turku University Central Hospital in Turku, Finland. "Accumulating evidence indicates the course of RA is determined early and that the optimal management of RA requires a swift diagnosis and immediate aggressive treatment."

Conducted over a two-year period, the study examined the impact of delaying treatment for RA symptoms, as well as the effectiveness of a single drug versus a combination of disease-modifying antirheumatic drugs (DMARDs). DMARDs are drugs that can reduce the signs and symptoms of RA and, in addition, can retard joint damage as evaluated by X-rays.

178 RA patients, comprised of both genders and various ages with a varying duration of symptoms from weeks up to two years, were divided into four groups. Two were treated with a single drug: one, shortly after the onset of symptoms; the other, after symptoms had persisted at least four months. Two were treated with a combination of DMARDs, including methotrexate, sulfasalzine, hydroxychloroquine, and prednisolone, under the same time period variables as their single-drug therapy counterparts.                  

At the study`s end, 35% of the patients who had received single-drug therapy within weeks to less than four months after experiencing symptoms showed positive signs of remission. Among those whose treatment had been delayed, however, only 11% reported strong relief from morning stiffness, joint tenderness and swelling, and persistent pain. Among the patients who had been treated with a combination of DMARDs, 42% had reached remission-in each group. This outcome demonstrated the consistent effectiveness of combined DMARD-therapy-even in cases of several months delay in treatment. Furthermore, when tested for joint damage, the patients treated with a combination of DMARDs scored significantly lower than those prescribed a single drug.                                                                                       
                                 
"Treatment of RA should aim at early clinical remission," Dr. Möttönen emphasizes. "The prerequisite for early initiation of therapy is the rapid admission of patients to specialist care. Thus, postgraduate education of general practitioners concerning the diagnosis, treatment, and outcome options of RA should be promoted actively." His research team concludes: Patients with active RA and a period of symptoms exceeding 3-6 months are candidates for aggressive treatment with a combination of DMARDs.

Noting the results of the study, three leading rheumatologists in an accompanying editorial emphasized r the need for making early specialty care a reality for RA patients-and the challenges. "A primary reason for delay in providing rheumatologic care is a relative shortage of rheumatologists-certainly relative to the prevalence of rheumatic diseases. The number of residents entering rheumatology fellowships has declined over the last decade, and the mean age of US rheumatologists is 51 years, which is among the oldest among clinical specialists," observe Dr. Theodore Pincus, of Vanderbilt University, Dr. Allan Gibofsky of Cornell University, and Dr. Michael Weinblatt of Harvard Medical School. They contend: "We must increase the number of residents entering our specialty, with more rheumatology in medical school curricula, greater visibility of clinical rheumatology in-house staff training programs, and improved compensation."

John Wiley & Sons