To investigate in rheumatoid arthritis (RA) patients the short- and long-term efficacy of unguided intra-articularly injections with betamethasone, and the impact of joint area, repeated injections, magnetic resonance imaging (MRI) pathology, anti-cyclic citrullinated peptides (anti-CCP) and IgM-rheumatoid factor (RF) status on long-term efficacy.
160 patients with early RA (<6 months' duration) received intra-articular betamethasone in all (max 4) swollen joints at each visit (2 week intervals for 8 wks, then every 4 wks) in combination with step-up DMARDs during 2 years. This was part of the CIMESTRA trial (1-2).
Short-term efficacy was assessed by EULAR good-response. Long-term efficacy by Kaplan-Meier plots of the joint-injection-survival (i.e. the time-span between injection and renewed synovitis).
Potential predictors of joint-injection-survival were tested.
1373 joints (wrists, knees, MCP, shoulders, ankles, PIP, elbows, MTP) were injected. Of these, 531 were 2nd injections in a previously injected joint, and 262 were 3rd. At baseline, the median DAS28 was 5.5 (IQR: 4.6-6.2), and the numbers of injections/dose of betamethasone given were: 4(3-4)/4 (3-4), declining to 0(0-2)/0 (0-1.5) at the following visits. At week 2, 4 and 6, respectively, 50.0%, 58.1% and 61.7% had achieved a good EULAR response.
After 1 and 2 years, respectively, 62.3%(95% C.I. 58.1-66.9%) and 55.5%(51.1-60.3%) of the joints injected at baseline had not relapsed. All joint areas had good 2-years’ joint-injection-survival, longest for the PIP-joints (73.7%(79.4-95.3%), p<0.01.
2-year joint survival was higher for 1st injections 56.6%(53.7-59.8%) than for 2nd 43.4%(38.4-49.0%) and 3rd injections 31.3%(25.0-39.3%), p<0.0001.
The cumulated dose of betamethasone after 2 years was: 11ml (IQR 7-17ml). The median intraarticular betamethasone dose during the first 2 years corresponded to less than 1 mg prednisolone per day.
Adverse events were mild and transient. High MRI synovitis score of MCP joints and anti-CCP were associated with poorer joint-injection-survival, whereas CRP and IgM-RF were not.
In early RA, intra-articular unguided injections of betamethasone in small and large peripheral joints together with DMARD treatment resulted in very rapid, effective and long-lasting inflammatory control. The cumulative dose of betamethasone was low, and the injections were well tolerated.
References: (1) Hetland ML et al. Arthritis Rheum 2006; 54:1401-9.
(2) Hetland ML et al. Ann Rheum Dis 2008: 67; 815-22.
Disclosure: M. L. Hetland, None; M. Østergaard, None; B. J. Ejbjerg, None; S. Jacobsen, None; K. Stengaard-Pedersen, None; P. Junker, None; T. Lottenburger, None; I. Hansen, None; L. S. Andersen, None; U. Tarp, None; A. Svendsen, None; J. K. Pedersen, None; H. Skjødt, None; T. Ellingsen, None; H. M. Lindegaard, None; K. Hørslev-Petersen, None.