Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis

TLDR

Delay in initiating disease‑modifying anti‑rheumatic drugs worsens rheumatoid arthritis outcomes, yet the optimal timing for early therapy remains unclear. The study aimed to determine whether a therapeutic window exists within the first few months of disease by comparing very early RA patients (median 3 months) to late early RA patients (median 12 months) in a matched case‑control design. Patients were followed for 36 months, with disease activity measured by DAS28 and radiographic damage assessed by the Larsen method, and differences were evaluated after 3 months of DMARD therapy. Very early RA patients showed significantly greater DAS28 improvement (2.8 ± 1.5 vs 1.7 ± 1.2) and slower radiographic progression than late early RA patients, supporting a therapeutic window within the first 3 months of treatment.

Abstract

Delay of disease-modifying anti-rheumatic drug (DMARD) therapy is a major contributing factor for poor outcome in rheumatoid arthritis (RA). Although early therapy has been shown to be particularly effective, there is still uncertainty about the optimal time point of DMARD introduction. We wanted to test if a therapeutic window of opportunity may exist within the first few months of the disease.In this case-control parallel-group study, 20 very early RA (VERA) patients with median disease duration of 3 months were age and gender matched to a group of 20 late early RA (LERA) patients with median disease duration of 12 months until first DMARD initiation. Follow-up time was 36 months. Primary outcome measures were the disease activity score (DAS28) and radiological joint destruction using the Larsen method.Already after 3 months of DMARD therapy we found a significant difference of improvement in favour of the VERA patients in the DAS28. This trend continued over the study period. At study end the DAS28 showed an improvement of 2.8+/-1.5 in the VERA vs 1.7+/-1.2 in the LERA group (P(c)<0.05). The Larsen scores showed a statistically significant retardation of progression in the VERA compared with the LERA.Our results indicate that there is a window of opportunity for highly successful treatment of RA in the first year, and especially within the first 3 months of therapy. Thus, early diagnosis and therapy may be the crucial step in achieving optimal control of disease progression and prognosis in RA.