Rheumatoid arthritis (RA) is the most common inflammatory form of arthritis. It is a systemic, chronic, autoimmune disease for which there is no current cure. However, it is clear that early diagnosis and aggressive treatment can make a tremendous impact on prognosis and prevention of disability. In fact, the aim for every patient should be to get them into remission as soon as possible. Many clinicians have adopted the approach of starting early aggressive therapy in the hopes of inducing remission rapidly. This methodology was validated by a recent study.

In early inflammatory arthritis, higher rates of remission are achieved if treatment is started early with conventional therapies and patients are more closely followed, according to research presented recently at the American College of Rheumatology Annual Scientific meeting in Boston (November 6-12, 2007).

A prospective observational cohort of 103 patients with early inflammatory arthritis were evaluated to determine how many patients reached remission 12 months after the start of DMARD (disease-modifying anti-rheumatic drug) therapy. Investigators also compared the different methods of measuring remission currently in use by clinicians.

The average age of the patients was 46 years, and 80% were women. All had symptoms of early arthritis for more than six weeks but for less than 12 months, and all had two or more swollen joints or one swollen joint in the hand plus one additional symptom of arthritis (e.g., morning stiffness).

Fifty-nine percent of patients in the group began combination DMARD therapy (methotrexate plus another DMARD such as sulfasalazine or hydroxychloroquine); 40 percent started only methotrexate. At six and 12 months, 13 percent and 28 percent of the patients had started biologic therapy, respectively. By 12 months, only 20% of patients required biologic therapies.

There are different criteria used for judging remission. And some remission criteria are stricter than others. However, using most accepted criteria, at the end of the 12 month period approximately half of the patients were able to achieve remission as a result of having prompted started an optimal DMARD therapy.

Since methotrexate was the DMARD that was common to both groups, this caused Vivian Bykerk, MD, University of Toronto, the lead investigator to comment, "This study highlights the benefits of early DMARD therapy using... methotrexate..."

"However further investigations are needed to identify those who will and will not benefit from this initial strategy and those who require a more aggressive treatment strategy."

The unspoken message also related to the more aggressive use of biologic agents in the treatment groups.

One difference of the Canadian study versus what is generally done in the United States is the tendency to use biologic therapy earlier instead of combination DMARD therapy.

The reasons for this are unclear but so far, it appears that biologic therapy is at least as safe and more effective than combination DMARD treatment which potentially has mores side effects related to the drugs used.

The long term side effects of biologic therapy are still not completely known. However, the experience of one biologic agent, etanercept (Enbrel), is now out to 10 years with no significant untoward problems noted.

In fact, there is the suggestion that many of the complications of rheumatoid arthritis such as cardiovascular events and lymphoma may be reduced using early intervention with biologic agents.

Rheumatologists vary in practice patterns. If you have RA and are not getting the results you desire, it's a good idea to find a rheumatologist who is aggressive and who will institute appropriate biologic therapy.