The long-term outcome and justification for early treatment

Abstract

The therapeutic options for rheumatoid arthritis (RA) remain disappointing, and the continued lack of overall progress in altering the course of the disease is frustrating. Whilst numerous trials demonstrate the benefits of slow-acting antirheumatic drugs (SAARDs) in the short term over 1-2 years (Research Subcommittee of the Empire Rheumatism Council, 1960; Huskisson et al, 1974; Pinals et al, 1986; Hamdy et al, 1987), there is little evidence for an overall effect on the ultimate outcome of rheumatoid disease determined over 15-25 years or longer (Scott et al, 1987; Pincus, 1988; Kushner, 1989). It is appropriate therefore to reappraise current rationale for treatment. Early active treatment of synovitis with SAARDs before radiological signs appear and irreversible destruction of cartilage and bone have occurred would seem the optimum time to commence therapeutic intervention. Studies have shown that disability develops most rapidly during the first years of disease, and thereafter is relatively slow (Sherrer et al, 1986). Radiological deterioration also occurs at a maximum rate at the onset of disease and parallels functional disability (Brook and Corbett, 1977; Beltran et al, 1987). This indicates that, despite the chronic nature of RA, a large amount of the ultimate functional deterioration may be determined over a relatively short time span at the beginning of the disease. A therapeutic implication is that treatment with SAARDs in an attempt to achieve 'disease modification' should precede the period of rapid disease progression to be effective. Such concepts have given the impetus and provided the logic for the establishment of early arthritis clinics. These exist at a number of centres. How successful are these early clinics and do they justify the investment of time and staff involved? This question is the background to this present volume; it is a specific and major issue which may alter the present conventional treatment of RA. In this chapter we present a synopsis of the outcome of conventionally treated RA and consider how this could be influenced by early treatment; we also examine the ways in which treatment policies, and especially the use of SAARDs, could be altered and tailored for the