Treatment Of Early Rheumatoid Arthritis Research Articles

Current therapies in rheumatoid arthritis: A Latin American perspective

Rheumatoid arthritis (RA) is a systemic inflammatory disease affecting the synovium of joints, tendons, and some extra-articular sites. RA prevalence in Latin America ranges from 0.4 to 1.6%. Early treatment of RA translates into a substantial reduction in the cost to society. In light of this, early disease clinics are being established in some countries. Barriers to RA management, such as delay in referral to rheumatologists and limited access to therapy, have been identified. Evidence-based treatment guidelines have been adapted by countries according to their own situations. The need for keeping accurate records of biologics prescribed has been addressed by biologic registries, thereby contributing toward a better understanding of rheumatic diseases and their treatment. Current biologics include the tumor necrosis factor (TNF)-α inhibitors (etanercept, infliximab, and adalimumab), B-cell depletion agent (rituximab), interleukin-6 receptor blocker (tocilizumab), and T-cell co-stimulatory blocker (abatacept). Future therapies include kinase inhibitors (tofacitinib and fostamatinib), alternative TNF-α inhibitors (golimumab and certolizumab), and biosimilars.

Adalimumab added to a treat-to-target strategy with methotrexate and intra-articular triamcinolone in early rheumatoid arthritis increased remission rates, function and quality of life. The OPERA Study: an investigator-initiated, randomised, double-blind, parallel-group, placebo-controlled trial

ObjectivesAn investigator-initiated, double-blinded, placebo-controlled, treat-to-target protocol (Clinical Trials:NCT00660647) studied whether adalimumab added to methotrexate and intra-articular triamcinolone as first-line treatment in early rheumatoid arthritis (ERA) increased the frequency of low...

Current therapies in rheumatoid arthritis: A Latin American perspective

Rheumatoid arthritis (RA) is a systemic inflammatory disease affecting the synovium of joints, tendons, and some extra-articular sites. RA prevalence in Latin America ranges from 0.4 to 1.6%. Early treatment of RA translates into a substantial reduction in the cost to society. In light of this, early disease clinics are being established in some countries. Barriers to RA management, such as delay in referral to rheumatologists and limited access to therapy, have been identified. Evidence-based treatment guidelines have been adapted by countries according to their own situations. The need for keeping accurate records of biologics prescribed has been addressed by biologic registries, thereby contributing toward a better understanding of rheumatic diseases and their treatment. Current biologics include the tumor necrosis factor (TNF)-α inhibitors (etanercept, infliximab, and adalimumab), B-cell depletion agent (rituximab), interleukin-6 receptor blocker (tocilizumab), and T-cell co-stimulatory blocker (abatacept). Future therapies include kinase inhibitors (tofacitinib and fostamatinib), alternative TNF-α inhibitors (golimumab and certolizumab), and biosimilars.

Pulmonary Mycobacterium abscessus disease in a patient receiving low-dose methotrexate for treatment of early rheumatoid arthritis

A 70-year-old woman with methotrexate (MTX)-refractory rheumatoid arthritis (RA) was referred to our hospital for introduction of biological therapy. On high-resolution computed tomography scans, the patient exhibited abnormal findings such as bronchiectasis and centrilobular small nodules, which were highly suggestive of pulmonary nontuberculous mycobacterial (NTM) disease. Although mycobacterial cultures of sputum specimens yielded negative results, cultures of bronchoalveolar lavage fluids grew Mycobacterium abscessus. Frequent follow-up chest radiographs indicated that the patient's pulmonary disease became rapidly worse in 1month following dose escalation of MTX and administration of low-dose prednisolone. Oral clarithromycin and levofloxacin, chosen on the basis of in vitro susceptibility testing, led to a dramatic recovery from this potentially life-threatening complication. Through our experience with this case, we have learned that (1) pulmonary M. abscessus disease can progress rapidly, even during nonbiological anti-RA therapy; (2) regular follow-up chest radiographs are useful to ensure timely implementation of anti-NTM treatment; (3) bronchoscopic testing should be considered when patients are suspected of pulmonary NTM disease but do not meet the diagnostic criteria; and (4) early isolation, identification, and susceptibility testing of causative NTM species are critical for favorable outcomes.

Prednisone on the threshold of rational use in the treatment of rheumatoid arthritis

This is a review of the evolution of the use prednisone in the treatment of rheumatoid arthritis (RA). Cortisone was introduced in 1949 and shortly thereafter, the Mayo investigators found that low divided doses with slow tapering were effective and caused fewer side effects. In 1959, a British double blind 2 year study of prednisolone treatment in early RA demonstrated effectiveness and reduced bony erosions. This experience was lost over time and empiricism and efforts to reduce side effects dominated practice for the next 35 years. Since 1995, a number of controlled studies of low single daily doses of prednisone in early RA have been reported by European investigators. They have shown clinical improvement, reduced bony erosions, augmentation of the effect of dmards and few side effects. During the last 25 years, the molecular actions of glucocorticoids have been elucidated. The time relationship of the dose to the biologic and clinical effects has been established. As a result of the information on the diurnal effect of glucocorticoids and the documentation of the effect occurring 5-6 hours after the dose and dissipating by 24 hours, a delayed release preparation of prednisone has been developed. With the rediscovery of the effectiveness of low single daily morning dose of prednisone in early RA by controlled studies and the demonstration of the onset and duration of the clinical effect of low dose of prednisone, it is now possible to use low doses of prednisone rationally and effectively in the treatment of RA. It remains to be determined whether a single morning, single evening or a twice a day low dose is the most effective and safe. It is doubtful if the new delayed release prednisone is any more effective than the usual immediate release prednisone if given at the same time.

The pathogenesis of rheumatoid arthritis in radiological studies. Part I: Formation of inflammatory infiltrates within the synovial membrane and I. Sudoł-Szopińska, K. Zaniewicz-Kaniewska, A. Warczyńska, G. Matuszewska, F. Saied, W. Kunisz The pathogenesis of rheumatoid arthritis in radiological studies. Part II: Imaging studies in rheumatoid arthritis.

In the recent years, musculoskeletal ultrasound (US) has been developing rapidly as a method evaluating the intensity of the inflammatory process in inflammatory joint diseases including rheumatoid arthritis (RA). The series of articles entitled: The pathogenesis of rheumatoid arthritis in radiological studies (parts 1 and 2)(1, 2) enable a deeper insight into the relation between the disease progression and changes visible on imaging such as US and magnetic resonance imaging (MRI). As the authors of the articles emphasize, these methods are important for the determination of the exact natural course of the disease, diagnostic differentiation of RA as well as monitoring its activity. The changes which could suggest RA in US exams are pathologies of the synovial membrane of the joints and tendon sheaths, joints and tendon sheaths effusion as well as erosions. On the other hand, the presence of enthesitis suggests the inflammation of the peripheral joints in the course of spondyloarthropathy such as psoriatic arthritis or ankylosing spondylitis. In the study of Narvaez et al., enthesitis, extensive bone marrow edema of the hand and wrist bones, diffuse soft tissue swelling of the hand and wrist and, to a certain extent, the involvement of the flexor tendons in MRI distinguished psoriatic arthritis from RA(3). In the US examination, at the early stage of arthritis, it is essential to check some joints for the presence of lesions which typically indicate that RA may develop in the later course of the disease. The research of Filer et al. shows that during the first US exam of the patients who developed RA, the following were diagnosed: subclinical synovitis of wrists, elbows, knees, ankle joints, metatarsophalangeal joints (MTP) and metacarpophalangeal joints (MCP)(4). The inflammation of large joints as well as proximal interphalangeal joints visualized during the US examination were of low prognostic value. The most important prognostic factor in RA development was the diagnosis of synovitis in the grey-scale US examination of the wrists and MCP joints as well as MTP joints synovitis in the power Doppler US. Therefore, US examinations of the wrists, MCP and MTP joints should always be performed in patients suffering from early arthritis with high-risk of RA development. In addition, it needs to be mentioned that joints ultrasound in patients receiving pharmacological treatment for early RA, facilitates the detection of minimum inflammatory activity with greater sensitivity than physical examination. Synovial hypertrophy with hypervascularization in power Doppler US enables the recognition of active inflammation in patients in a stage of clinical remission. In a study based on 48 patients with early RA, the US examination confirmed the clinical remission in 67% of the subjects(5). Simultaneously, the exacerbation of the disease occurred in 47% of the patients in remission of early arthritis in whom the power Doppler signal was present. Out of the patients in whom there was no power Doppler signal in the synovial membrane, the disease exacerbation occurred in merely 20% of cases.

Treatment with adalimumab in amyloidosis secondary to rheumatoid arthritis: two case reports.

Rheumatological diseases and, firstly, rheumatoid arthritis (RA) remain a major cause of secondary amyloidosis. The emergence of biological agents such as adalimumab in the early treatment of RA can be an effective alternative to stop the development and progression of secondary amyloidosis. Not all patients will respond the same way to treatment; we must consider associated comorbidity, the poor prognosis factors for predicting therapeutic response and possible adverse effects. In the adverse effects of biological therapies, there has been an increase in the rate of lethal infections and congestive heart failure. We present two cases with renal amyloidosis secondary to RA who had a different clinical course: our 1st case had a good response to Adalimumab while the 2nd case evolved unfavourably after treatment, and died from cardiovascular complications.

Treatment of Early Rheumatoid Arthritis in a Multinational Inception Cohort of Latin American Patients

Treatment of rheumatoid arthritis (RA) has evolved dramatically in the last decade. However, little is known about the way rheumatologists in Latin America treat their patients in clinical practice, outside the scope of clinical trials. The objective of this study was to describe treatment patterns at disease onset in early RA with data from a large, multicenter, multinational inception cohort of Latin American patients. Consecutive patients with early RA (<1 year of disease duration as diagnosed by a rheumatologist) from 46 centers in 14 Latin American countries were enrolled in the study. Clinical data, laboratory assessments, and a detailed registry on type of prescriptions were collected at baseline and at 3, 6, 12, 18, and 24 months of follow-up. Hands and feet x-rays were obtained at baseline and at 12 and 24 months. All data were captured in Arthros 6.1 database. Continuous variables were expressed as means and SDs, and categorical variables were expressed as percentages and 95% confidence intervals (95% CIs). Only therapeutic data at baseline are presented, corresponding to the period between disease onset and second visit (3 months). A total of 1093 patients were included. Eighty-five percent were female, and 76% had a positive rheumatoid factor. Mean age at diagnosis was 46.5 (SD, 14.2) years, and mean disease duration at the first visit was 5.8 (SD, 3.8) months. Between baseline and second visit (3 months), 75% of patients (95% CI, 72%-78%) received disease-modifying antirheumatic drugs. Methotrexate (MTX) alone or in combination was the most frequently used (60.5%), followed by antimalarials (chloroquine or hydroxychloroquine, 32.1%), sulfasalazine (7.1%), and leflunomide (LEF, 4%). In 474 patients (43%), initiation of disease-modifying antirheumatic drugs was within the first month after the first visit. In addition, 290 patients (26%; 95% CI, 23%-29%) received combination therapy as initial treatment. The most frequently used combinations were MTX + chloroquine (45%), MTX + hydroxychloroquine (25%), and MTX + sulfasalazine (16%). Eleven patients (1%; 95% CI, 0.5%-1.8%) received biologics. Sixty-four percent (95% CI, 60%-66%) received corticosteroids. Of those, 80% (95% CI, 77%-84%) received 10 mg of oral prednisone or less. In this cohort of Latin American patients with early RA, most patients received MTX very early in their disease course. Combination therapy was used approximately in 1 of every 4 patients as initial therapy. Biologics were rarely used at this early stage, and low-dose prednisone was commonly used.

Predictors of change in bodily pain in early rheumatoid arthritis: An inception cohort study

ObjectiveTo investigate possible predictors for lack of pain improvement after 1 year of treatment for early rheumatoid arthritis (RA).MethodsThe Early Rheumatoid Arthritis Network (ERAN) database was used for analysis of baseline and 1-year pain data. The ERAN is a hospital-based inception cohort of 1,189 people. Short Form 36 questionnaire bodily pain scores were used to calculate change in pain at 1 year as the outcome. The proportion of the Disease Activity Score in 28 joints (DAS28) attributable to patient-reported components (joint tenderness and visual analog scale score; DAS28-P) at baseline was derived as a predictor. Predictors of less improvement in pain were investigated using adjusted odds ratios (ORadj) generated by logistic regression, adjusting for 14 additional clinical and demographic covariates.ResultsGreater pain at baseline was associated with sex, high DAS28, worse mental health, and smoking. Most patients with early RA reported incomplete improvement in bodily pain after 1 year. The DAS28-P index did not significantly change in the patients whose disease remained active. Less improvement in pain was predicted by female sex (ORadj 3.41, 95% confidence interval [95% CI] 1.35–8.64) and a high DAS28-P index at baseline (ORadj for tertiles 2.09, 95% CI 1.24–3.55). Other conventional RA risk factors did not predict pain changes.ConclusionThe factors most likely to predict less improvement in pain in early RA are female sex and a high DAS28-P index. A high DAS28-P index may reflect greater contributions of noninflammatory factors, such as central sensitization, to pain. Strategies in addition to inflammatory disease suppression may be required to adequately treat pain.

Infliximab in Russian clinical practice

The study of infliximab began (INF) in Russia in 2001. It was the first genetically engineered biological agent (GEBA) registered in our country to treat patients with rheumatoid arthritis (RA). With the advent of infliximab, a Russian biological rheumatoid arthritis therapy registry started its work. In October 2005, it was set up on the basis of GEBA centers founded in the leading rheumatology clinics of Russia. Objective: to generalize the Russian experience in using INF (its efficacy, tolerance, and side effects) in patients with RA in real clinical practice within the framework of a multicenter observational study. Subjects and methods. The register included patients with a valid diagnosis of RA in whom INF treatment was first started. The main indication for this was previous basic therapy failure. This investigation analyzed 396 patients receiving INF therapy. Prior to INF administration, all the patients were examined to identify whether they had possible latent tuberculosis, by applying chest X-ray study and Mantoux test. The European League Against Rheumatism criteria were used to evaluate the efficiency of INF therapy. The relationship between the therapeutic effects of the drug and its cumulative dose was specially used. The trend in X-ray progression was estimated using the Sharp method modified by van der Heijde. INF was given in a dose of 3 mg/kg by the classical regimen: at 0, 2, and 6 weeks, then every 8 weeks. The main assessment periods were at 22 and 46—54 weeks. Results. Analysis of the data of real clinical practice in Russia demonstrates that the use of INF in RA patients with the inadequate effect of traditional disease-modifying antirheumatic drugs (DMARDs) is able to cause a rapid and pronounced reduction in disease activity. There is significant evidence that the IFN-treated patients with RA had also suppressed bone destruction. INF treatment for early RA gives rise to remissions more frequently in the early stage of therapy than that for extensive-stage disease. INF was shown to have a clear dose-dependent effect: in the patients receiving more than 4 infusions of the drug, bone destruction was more noticeably suppressed than in those having its fewer infusions. In most cases, suppressed destruction was accompanied by clinical improvement. A significant therapeutic effect was seen when both an annual course of INF and average (5—7 infusions per year) doses of the drug were used. The results of the analysis suggest that the probable efficiency of INF therapy increases in RF-negative patients with lower baseline RA activity and fewer HAQ scores. INF was quiet satisfactorily tolerated and caused no unusual side effects. Conclusion. The Russian experience in using INF strongly suggests that it is effective in real practice in severe RA resistant to therapy with traditional DMARDs.

Increasing Treatment in Early Rheumatoid Arthritis Is Not Determined by the Disease Activity Score But by Physician Global Assessment: Results from the CATCH Study

To determine the factors most strongly associated with an increase in therapy of early rheumatoid arthritis (ERA). Data from the Canadian Early Arthritis Cohort (CATCH) were included if the patient had ≥ 2 visits and baseline and 6 months data. A regression analysis was done to determine factors associated with treatment intensification. Of 1145 patients with ERA, 790 met inclusion criteria; mean age was 53.4 years (SD 14.7), mean disease duration 6.1 months (SD 2.8), 75% were female, baseline Disease Activity Score-28 (DAS28) was 4.7 (SD 1.8) and 2.9 (SD 1.8) at 6 months for included patients. Univariate factors for intensifying treatment were physician global assessment (MDGA; OR 7.8 and OR 7.4 at 3 and 6 months, respectively, p < 0.0005), swollen joint count (SJC; OR 4.7 and OR 7.3 at 3 and 6 months, p < 0.0005), and DAS28 (OR 3.0 and OR 4.6 at 3 and 6 months, p < 0.0005). In the regression model only MDGA was strongly associated with treatment intensification (OR 1.5 and OR 1.2 at 3 and 6 months, p < 0.0005); DAS28 was not consistently predictive (OR 1.0, p = 0.987, and OR 1.2, p = 0.023, at 3 and 6 months). DAS28 was the reason for treatment intensification 2.3% of the time, compared to 51.7% for SJC, 49.9% for tender joint count, and 23.8% for MDGA. For the same SJC, larger joint involvement was more likely to influence treatment than small joints at 3 months (OR 1.4, p = 0.027). MDGA was strongly associated with an increase in treatment at 3 and 6 months in ERA, whereas DAS28 was not. Physicians rarely stated that DAS28 was the reason for increasing treatment.

Timing the therapeutic window of opportunity in early rheumatoid arthritis: proposal for definitions of disease duration in clinical trials

The effects of treatment in early rheumatoid arthritis (RA) and the consequences of delayed therapy represent important areas for research. The concept of a ‘window of opportunity’ is now well...

Treatment Strategies in Early Rheumatoid Arthritis and Prevention of Rheumatoid Arthritis

Data now suggest that current strategies in the treatment of rheumatoid arthritis (RA) should focus on early identification and diagnosis, followed by early initiation of DMARD therapy. Initiation of treatment in early RA-ideally, less than 3-6 months after symptom onset-improves the success of achieving disease remission and reduces joint damage and disability. While the optimal treatment regimen in early RA is unclear, use of initial DMARD mono- or combination therapy with prompt escalation to achieve low disease activity or remission is an appropriate approach. Ultimately, the goal of RA management should be the prevention of inflammatory joint disease and, thereby, prevention of disability. To date, studies have shown that pharmacologic interventions can delay progression from undifferentiated inflammatory arthritis to classifiable RA. However, further investigation is needed to identify asymptomatic individuals at high risk for future RA and to intervene early enough in the pathogenesis of RA to prevent progression to clinical disease.

A framework for improving the quality of care for people with psoriasis

SummaryA lack of national guidelines in some countries and lack ofconsensus amongst those that do exist in others is problematic.Specifically, poor and inconsistent advice on initiating and opti-mising therapeutic interventions is a barrier to improving out-comes. While European guidelines can help to fill the gap incountries without national guidelines, their role should primar-ily be to strengthen and harmonise existing guidelines, and toprovide a framework for the development of new nationalguidelines. They therefore need to lead the provision of advicethat is not given in existing guidelines. Limited awareness ofguidelines and increasing pressures on patient consultation can Figure 5 The concept of cumulative life course impairment(CLCI) in psoriasis. 22 CLCI results from an interaction betweenthe burden of stigmatisation, physical and psychological co-mor-bidities; and coping strategies and external factors. Significantimpairment may occur in patients with ineffective coping strate-gies and limited social support, even if they have a small burden.This impairment may be less in patients with effective copingstrategies and strong social support networks, even if the bur-den is large. (Figure adapted from Kimball 2010.)

Leflunomide monotherapy in patients with early rheumatoid arthritis: Results of the Russian national Arava mono study

The treatment of early rheumatoid arthritis (RA) is usually started using one of the synthetic disease-modifying antirheumatic drugs. The choice of these drugs is very limited and leflunomide (LEF) is one of the most promising agents. The present study assessed the results of using the standard LEF regimen for patients with early RA in the everyday clinical practice of Russian health care facilities. Subjects and methods. The study enrolled the patients followed up in 20 medical centers of the Russian Federation in May 2008 to January 2010. The RA patients who met the 1987 American College of Rheumatology (ACR) classification criteria, had a less than 2-year history of the disease, and had not received LEF before were included. All the patients were above 18 years of age and they signed an informed consent form. The physicians were recommended to give the drug in a dose of 100 mg/day for the first 3 days, then 20 mg/day continuously. If adverse reactions occurred, the dose might be reduced to 10 mg/day. The patients were examined before and 12, 24, 36, and 48 weeks after LEF therapy. The efficiency of the treatment was evaluated by the European League Against Rheumatism (EULAR) classification criteria using DAS 28 scores, by the ACR criteria, and functional changes using HAQ scores and quality of life using the EQ-5D questionnaire. Results. The study included 484 patients with RA. Its diagnosis corresponded to the 1987 ACR criteria. There were 80 men and 404 women in this group. The patients’ mean age was 48.1±13.4 years; the mean duration of the disease at its onset was 14.1±12.8 months. A significant decrease in the number of patients with high DAS 28 scores was recorded every 12 weeks during the treatment. It reduced from 355 (73.3%) to 41 (8.5%) by the end of the observation. At the same time, there was a significant increase in the number of patients with low activity and remission every 12 weeks (p < 0.01). During the last visit, a remission was recorded in 57 (11.8%) patients and low disease activity in 59 (12.2%) patients. Twelve weeks after initiation of treatment, 210 (43.4%) patients achieved a significant improvement according to the EULAR criteria. During a subsequent follow-up, the number of patients with a considerable improvement increased statistically significantly every 12 weeks and there were 373 (77%) patients by the end of the follow-up. Efficiency evaluation showed a 20% response according to the ACR criteria in 154 (31.8%) patients after the first 12 weeks. There was a significant rise in the number of patients with a 20% ACR improvement within the first 36 weeks of the follow-up and there were 323 (66.7%) patients following 48 weeks. The number of patients with 50% and 70% ACR responses considerably increased throughout the observation (p < 0.01). After 48-week treatment, 141 (29%) and 38 (8%) patients showed 50% and 70% ACR responses, respectively. The therapy significantly improved quality of life, as estimated by EQ-5D questionnaire, and resulted in a considerable functional improvement according to HAQ scores. ARs were seen in 51 (10.5%) patients during the study. At the follow-up, LEF was discontinued in 58 patients, including 23 (4.8%) because of its inefficiency, in 9 (1.9%) due to ARs, and in 26 (5.4%) for other reasons. The efficiency of the therapy and the rate and causes of its withdrawal were comparable in the patients receiving LEF in accordance with the standard regimen using its saturating dose in the first 3 days and in those who did not take the saturating dose. Conclusion. The standard treatment regimen of LEF using its high doses in the first 3 treatment days in patients with early RA enables the inflammatory activity to be effectively inhibited and does not cause any substantial increase in the frequency of ARs.

Decline in work disability caused by early rheumatoid arthritis: results from a nationwide Finnish register, 2000–8

ObjectivesTo study whether the work disability (WD) rates in early rheumatoid arthritis (RA) have changed in Finland, where the treatment of RA has long been active but has intensified further...

Effect of very early treatment in rheumatoid arthritis on bone oedema and synovitis, using magnetic resonance imaging

Objective: To evaluate the magnetic resonance imaging (MRI) findings of hand involvement before and 1 year after treatment in patients with early rheumatoid arthritis (RA).Method: MRI of the dominant hand was performed in 22 patients fulfilling the new criteria for early RA. The patients were divided into three groups. Nine had very early RA (VERA; disease duration < 3 months), seven had early RA (ERA; disease duration < 6 months), and six had established RA (ESTRA; disease duration > 12 months). The MRI protocol consisted of fat-suppressed T2, and plain and contrast-enhanced T1-weighted sequences. Assessment of bone marrow oedema, synovitis, and bone erosions was performed by the OMERACT RA MRI scoring system. Patients were treated with methotrexate (MTX) 0.2 mg/kg/body weight/week and prednisone 7.5 mg/day. Clinical assessment was evaluated using the Disease Activity Score for 28 joint indices (DAS28).Results: After treatment, a significant decrease was observed: (a) in DAS28 of VERA (6.2 ± 0.9 vs. 2.4 ± 1.2), ERA (5.3 ± 0.8 vs. 2.8 ± 1.0), and ESTRA patients (5.7 ± 8.0 vs. 2.7 ± 0.7; p < 0.05); (b) in bone oedema (16.77 ± 13.78 vs. 5.88 ± 6.31) and synovitis (12.44 ± 6.44 vs. 2.88 ± 3.25) of VERA patients; and (c) in synovitis (7.57 ± 6.32 vs. 1.42 ± 1.81) of ERA patients (p < 0.05). No significant difference was found in erosions in any group.Conclusion: Bone marrow oedema and synovitis decrease significantly when RA is diagnosed and treated early. MRI is useful in the early detection of these changes. MTX treatment resulted in a significant decrease in DAS28 score and significant improvement in bone oedema and synovitis.

Tight Disease Control in Early RA

The past decade has brought increasing evidence to support aggressive therapeutic intervention in early rheumatoid arthritis (RA). Treat-to-target strategies that focus on frequent monitoring and treatment adjustments to achieve states of low disease activity or clinical remission have shown superior long-term results. Both oral disease-modifying antirheumatic drugs and biologic agents are effective in treating early RA. It remains unclear if initial combination therapy or biologic use is more effective in early active disease as compared with the traditional approach. The authors review various studies on the treatment of early RA with a focus on studies with a treat-to-target approach.

Changes in Proliferation Kinetics of T Cells: A New Predictive Cellular Biomarkers for Early Rheumatoid Arthritis?

ObjectiveIt has been demonstrated that early treatment of rheumatoid arthritis (RA) patients prevents further joint damage and disability, but biomarkers enabling early RA to be distinguished within the undifferentiated arthritis (UA) cohort are still being sought.PurposeThe aim of the research was to study the pathomechanism of initiation and progression of UA→RA and to find such new predictive biomarkers on the basis of functional studies of the immune system.Methods55 patients with UA were enrolled into the study and followed up for 2 years. The dynamic parameters of proliferation of the peripheral blood CD4+ T cells were recorded at the UA stage. During the follow-up study, standard diagnostic procedures were performed to make the final diagnosis. Comparison of the CD4+ T cell proliferation parameters in the UA-RA and UA-non-RA patients was conducted after the final diagnosis was established.ResultsOur studies showed that the G0-G1 transition time, the cell cycle duration, the number of cell divisions per dividing CD4+ cells and the percentage of dividing CD4+ T cells differed significantly between UA-RA and UA-non-RA patients. Moreover, these proliferation parameters achieved higher specificity and sensitivity in the detection of early RA within UA patients compared to the routine serological tests available.ConclusionThe proliferation parameters of CD4+ T cells reflect central pathophysiological changes in RA and can be used as new biomarkers for early RA diagnosis, which would enable the international rheumatology recommendation to be achieved concerning the early diagnosis and treatment of RA patients.

Combination Therapy Including Glucocorticoids: The New Gold Standard for Early Treatment in Rheumatoid Arthritis?

In this issue, Bakker and colleagues report improved outcomes for patients with early RA treated with MTX plus prednisone compared with those treated with MTX plus placebo. The editorialist notes t...