New treatment approaches in early RA br/The key issues in early rheumatoid arthritis (RA) need to be considered with the overall context of established RA. This disorder remains the commonest long-term inflammatory disease in the UK and other developed countries. It affects about 1% of adults, and has a marked female preponderance in the region of 3:1. RA lasts for many years and is characterized by joint inflammation, progressive joint destruction—mainly due to bone erosions—and increasing disability. A substantial minority of patients have systemic features. These include rheumatoid nodules and lung disease. There are also increased risks of coronary artery disease and infection. Severe RA shortens life expectancy. What is early RA? br/Historically, early RA was considered as less than 5 years disease, but by the early-1990s this had decreased to 24 months or less, with greater emphasis on the first 12 months. Currently, many rheumatologists wish to see patients with early RA at the first available opportunity. The proportion of rheumatologists who wish to see patients within 6 weeks from symptom onset doubled from 9% in the year 1997 to 17% in 2003, though not all patients were seen so rapidly. br/Conventional DMARD or biological combinations br/Only one study has directly compared conventional combinations with biologic combinations. This is aptly named as BeSt trial. This study compared four different treatment strategies in 508 RA patients with early disease. These strategies comprised sequential DMARD monotherapy, step-up combination DMARD therapy, initial combination therapy with tapered high-dose prednisone (the COBRA regimen) and initial combination therapy with a TNF-inhibitor (infliximab). The study showed that initial combination therapy including either prednisone (in the COBRA regimen) or infliximab gave earlier functional improvement and less radiographic damage after 12 months of either sequential monotherapy or step-up combination therapy. br/Conclusions There is some evidence, albeit incomplete, that combination therapy using TNF-inhibitors is most effective. However, its high cost and uncertain long-term risks may dissuade some experts from using it. A key uncertain question when and in whom these high-cost new treatments should be started.
