OP0007 CLINICAL AND RADIOLOGICAL EFFICACY OF DIFFERENT TREATMENT STRATEGIES: 2 YEAR FOLLOW-UP OF THE BEST STUDY
Y. P. M. Goekoop-Ruiterman, J. K. de Vries-Bouwstra, D. van Zeben, P. J. S. M. Kerstens, J. M. W. Hazes, A. E. Zwinderman, F. C. Breedveld, C. F. Allaart, B. A. C. Dijkmans

This abstract summarizes the clinical and radiographic progression data for the BeST study at 2 years. The study compared the ability of four treatment approaches to minimize disease progression in patients with early RA. Health Assessment Questionnaires (HAQ) and Sharp-van der Heijde scores were assessed.

Patients with active rheumatoid arthritis (RA) having symptoms <2 years were randomized to 1 of 4 treatment groups:

1. Sequential monotherapy starting with methotrexate (MTX), then sulphasalazine (SSA), then leflunomide, then MTX with infliximab (IFX) (Group 1, n=126);
2. Step-up combination therapy starting with MTX, then adding SSA, then hydroxychloroquine and then prednisone, then switching to MTX with IFX (Group 2, n=121);
3. Initial combination therapy with MTX, SSA and a tapered high dose prednisone, then MTX with cyclosporin A and prednisone, then MTX with IFX (Group 3, n=133);
4. Initial combination therapy with MTX and IFX, next leflunomide, then SSA, then MTX with cyclosporin A and prednisone (Group 4, n=128).

Results: 42% of patients in all of the groups achieved clinical remission by 2 years. However, patients in groups 3 & 4 had significantly less radiographic progression. These groups also had less adjustments made in their treatments over time. The table below contains the 2 year data.

Adverse events and the number of dropouts among all 4 groups were similar.

Conclusion: While all four therapeutic approaches resulted in similar numbers of patients achieving clinical remission after 2 years, initiation with combination therapy with prednisone or infliximab resulted in more rapid clinical and functional improvement, a lower relative risk for having progressive disease and fewer treatment adjustments than sequential monotherapy and step-up combination therapy.

Editorial Comments: The better radiographic scores achieved in the more aggressive treatment groups (groups 3 and 4) adds evidence to support the strategy of early aggressive therapy for RA. However, an equally important finding from the study is that similar clinical outcomes were achieved by all of the patient groups when patients were followed by DAS scoring and therapy changed based on pre-established protocols. Thus, one might argue that rheumatologists need to focus more on measuring disease activity in response to therapy, regardless of which therapy is chosen. The BeSt study is to run 5 years and it will be very interesting to see how early control of disease and choice of initial treatment affects long term radiographic scores, disability and future severity of disease.

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