Presentation: Tight Control in the Treatment of Rheumatoid Arthritis: A New Paradigm (2007)

340 Tight Control in the Treatment of Rheumatoid Arthritis: A New Paradigm

PURPOSE: New strategies in the treatment of rheumatoid arthritis (RA) provide the opportunity to aim for low disease activity and even remission. In trials, comparison of fixed strategies is more and more replaced by comparison of strategies tailored to individual patients, aimed at meeting predefined levels of low disease activity or remission. This goal that could be applied in daily clinical practice too, is a new paradigm called “tight control”. Our aim was to evaluate the efficacy and feasibility of tight control by reviewing this method in published randomized trials in patients with early RA.

METHODS: The literature base ‘Pubmed’ was searched using the following terms: ‘rheumatoid arthritis’, ‘randomized trial’, ‘treatment strategy’, ‘low disease activity’, and ‘remission’. There had to be at least one intervention group with the principle of tight control. This search yielded 3 trials: the TICORA study (1), FIN-RACo trial (2), and the BeSt study (3) in addition to our own CAMERA-I study (4).

RESULTS: Of all 4 studies, the 2 year results are discussed here. In the TICORA study 65% of the patients in the tight control group and 16% of the contrast group received remission, based on the predefined DAS level < 1.6 (p<0.0001). In the FIN-RACo trial aimed at DAS28 < 2.6, in the tight control group 51% of patients received remission versus 16% in the contrast group (p<0.001). In the CAMERA-I study, 51% of the patients in the tight control strategy using a computer decision model received remission, versus 39% in the contrast strategy (p=0.04). The BeSt study consisted of only tight control groups aimed at a DAS < 1.6; remission was achieved in 38 - 46% of the patients. This can be compared with the range of remission in earlier trials of 13 - 38%.
The interval between assessments to tailor the therapy to individual patients was 1 month for the tight control groups in TICORA and CAMERA-I, and 3 months in FIN-RACo and BeSt. The numbers of patients receiving remission were 65% and 51% in the studies with monthly adjustment of therapy versus 51% and 46-38% with adjustment each 3 months. In none of the 4 studies limitations with respect to feasibility of tight control were reported.

CONCLUSIONS: Tight control seems an effective and feasible strategy in treating RA patients in clinical trials and probably also in daily clinical practice.

1. Grigor, et al. Lancet 2004; 364: 263-9.
2. Mäkinen, et al. J Rheumatol 2007; 34: 316-21.
3. Goekoop-Ruiterman, et al. Ann Intern Med 2007; 146: 406-15.
4. Verstappen, et al. Ann Rheum Dis (in press)

 M.F. Bakker, None; J.W. Jacobs, None; J.W. Bijlsma, None.