Page 63 - THE EVOLUTION OF EARLY ARTHRITIS AND CARDIOVASCULAR RISK Samina A. Turk

HOW DOES ESTABLISHED RHEUMATOID ARTHRITIS DEVELOP
adalimumab aimed at remission versus usual care in oligoarthritis patients, did not
show a better outcome for aggressive treatment, although there was a trend toward
less radiographic damage in the aggressively treated group(95). In a larger two-step
study aiming at early remission of early oligoarthritis or RA (IMPROVED study), similar 3 rates of remission were achieved after 6 months of 61%. Of those not in remission at 6
months, more patients achieved remission at 12 months with adalimumab than with conventional disease-modifying antirheumatic drug (DMARD) combination therapy(96).
In conclusion, intervening in the early phase of clinical arthritis with minimal joint involvement leads to similar remission rates as are found in early RA, and there is not much evidence supporting the halting of progression from UA to RA. This suggests that it is not easy to further enhance the benefit of treating RA patients early, by treating patients with fewer involved joints even earlier in the disease course.
The broader question to what extent the transition to established RA can be prevented in patients with early RA is answered by the relative but not yet absolute success of early targeted treatment during the window of opportunity. Secondary prevention in this case could be defined as the goal of achieving and maintaining remission by early and aggressive treatment followed by minimization of therapy(97). Spontaneous remission occurs frequently in early arthritis, especially seronegative arthritis, and only rarely in established RA (Fig. 1)(61). Patients who achieve early remission can sometimes maintain their remission for prolonged periods after stopping medication(98). For patients with established RA in remission, it is less often possible to maintain a drug-free remission(99, 100). Taken together, it appears that DMARD-free remission can occur (13-50%), and it is not so rare as previously thought (4-6%). At any rate, there is hope that by achieving early remission with aggressive therapy, the disease can be controlled with less total medication in the long run than with milder treatment regimens.
Figure 1. Remission in different stages of rheumatoid arthritis
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