Conventional monotherapy compared to a "sawtooth" treatment strategy in the radiographic progression of rheumatoid arthritis over the first eight years.

OBJECTIVE: To describe the treatment with disease-modifying antirheumatic drugs (DMARDs) in two inception cohorts of rheumatoid arthritis (RA) patients and to compare their radiographic outcomes. METHODS: A recent onset RA cohort was collected in Heinola in 1973-1975, and another in Jyväskylä in 1983-1989. The cohorts were followed up prospectively and treated with available DMARDs. The radiographic outcomes of 103 and 85 seropositive cohort patients from Heinola and Jyväskylä respectively were assigned Larsen scores (0-100) for their wrist, hand and foot radiographs in years 0, 1, 3, and 8, and compared with each other. RESULTS: In this study it was seen that DMARD treatment for RA became more extensive over time. The earlier cohort patients were treated with gold sodium thiomalate, chloroquine and D-penicillamine, while 8 additional DMARDs and various DMARD combinations were used for the later cohort patients. At the 8 year visit, 23%, 33%, and 2% of the Heinola patients, and 6%, 45%, and 21% of the Jyväskylä patients respectively were being treated with chloroquine, other single DMARDs, or DMARD combinations. Destruction in the peripheral joints remained lower in the more extensively treated cohort; from 0 to 8 years the median Larsen score increased from 1 to 25.5 and from 0 to 12 (p = 0.001) for the Heinola and the Jyväskylä patients, respectively. CONCLUSION: Our result supports a role of DMARDs in preventing joint destruction in RA in the long-term.

A retrospective study of treating RA patients with various combinations of slow-acting antirheumatic drugs in a county hospital.

During the period 1/1990-9/1995 a total of 311 RA patients were challenged 458 times with 52 different COMBOs. As the first COMBO methotrexate (MTX), sulphasalazine (SSZ), im gold (GOLD), and hydroxychoroquine (HCQ) were combined with each other in 272/311 cases. The respective six and 12 months survivals of these COMBOs were 68.6% (95% CI 63.0% to 74.3%) and 53.6% (95% CI 47.4% to 59.9%). Inefficacy (27.9%), rather than adverse events (23.5%) or other causes (16.9%) was the leading reason for the discontinuations. Only in five cases (1.8%) these COMBOs were discontinued due to a remission. Not a single adverse event related to a COMBO treatment was judged as serious. The mean survival time for COMBOs including MTX (24.0 months; 95% CI 20.6 to 27.4) was statistically significantly longer than the respective time for COMBOs without MTX (14.5 months; 95% CI 11.2 to 17.7). We conclude that, when meticulously monitored, the treatment with COMBOs is safe. However, their efficacy on patients with advanced RA is modest. The survival time for COMBOs including MTX is longer than COMBOs without MTX.