Abstract
Recent data have shown that disability and joint destruction in rheumatoid arthritis (RA) occur early on in the course of the disease and progress rapidly. It has been shown that in the early stages of RA, disability is attributed to increased disease activity, whereas later in the course of the disease, disability results from irreversible joint damage. These findings support the need to develop treatment strategies that will rapidly bring the disease under control, with the ultimate goal of alleviating symptoms and halting progressive joint damage. A number of such strategies have been evaluated, including the early administration of a biologic agent alone or in combination with high-dose methotrexate. Other, more recent treatment strategies include the tight control of disease activity by targeting specific outcomes necessary for decision making; the use of biologic agents for the treatment of moderate disease; and the induction of remission with a biologic agent early in the course of disease, followed by maintenance therapy using a conventional disease-modifying antirheumatic drug. The substantial positive effect these strategies have on patient outcomes supports the concept that the optimal management of RA involves aggressive early therapy combined with close monitoring of disease progression and modification of ineffective therapeutic strategies.
Key Points
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Early use of biologic agents is more effective than use later in disease
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Combination treatment with a biologic agent and methotrexate is more effective than either alone
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Patients with moderate disease have better outcomes after treatment than patients with severe disease
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Intensive therapy with dose monitoring and adjustments in therapy (tight control) is more effective than routine care
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Acknowledgements
The author wishes to thank Nadine Daneman and Correna LeCoure for their excellent administrative assistance, and Rick Davis, MS, RPh, whose work was funded by Amgen Inc, for providing editorial assistance in the preparation of this manuscript.
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EC Keystone is a Professor of Medicine at the University of Toronto, a Senior Consultant in Rheumatology at Mount Sinai Hospital, and the Chairman of the Canadian Rheumatology Research Consortium in Toronto. He is the Director of The Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, and heads the Advanced Therapeutics Division, in Toronto, Ontario, Canada
- Edward C Keystone
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The author has conducted research for the following companies: Amgen, Bristol-Myers Squibb, Centocor Inc, Hoffman-La Roche Ltd (Canada), Abbott laboratories, Novartis, Schring Plough Inc., Targeted Genetics, Therakos, Wyeth Pharmaceuticals.
The author has acted as a Consultant or a member of the Advisory Board for the following companies: Abbott Laboratories, Amgen, Aventis Pharma, Bristol-Myers Squibb, Celltech, Centocor Inc., Genentech, Hoffman La-Roche Ltd, Schring Plough Inc., Targeted Genetics, Wyeth Ayerst, Genentech.
The author is a Speaker for the following companies: Abbott Laboratories, Amgen, Aventis Pharma, Centocor Inc., Genentech, hoffman-La Roche Ltd, Schering Plough Inc, Wyeth.
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Keystone, E. Strategies to control disease in rheumatoid arthritis with tumor necrosis factor antagonists—an opportunity to improve outcomes. Nat Rev Rheumatol 2, 594–601 (2006). https://doi.org/10.1038/ncprheum0340
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DOI: https://doi.org/10.1038/ncprheum0340
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