RA treatment requires a more intensive, targeted approach

Responding early to anti-tumour necrosis factor drugs is important in estimating the long-term effectiveness of therapy and could be used to optimise treatment strategies, new data presented at the European League Against Rheumatism (EULAR) meeting in Rome suggests.

New guidelines issued by EULAR at the meeting recommend a more intensive, targeted approach to the management of RA and an expert committee has produced 15 recommendations. Principal amongst these are proposals to aim for patients to achieve a state of low disease activity or remission by adjusting treatment every one-three months. EULAR president Paul Emery said: “The treatment target should be reached, or almost reached, within three months and definitely attained by a maximum of six months as we know that such an approach is associated with a better clinical, radiographic and functional outcome.”

A new follow-up of patients from the RAPID-1 study of UCB's Cimzia (certolizumab pegol), a novel PEGylated anti-TNF, presented at EULAR showed that the patients treated with Cimzia and methotrexate who achieved a rapid and greater response to treatment by week 12 were more likely to have low disease activity two years later than patients who achieved a slower or lower response to treatment. Patients in the RAPID-1 study had established disease. Lead investigator of the RAPID-1 study, Professor Edward Keystone, professor of medicine at the University of Toronto, said: “We are seeing a new concept emerging from these data that even in established disease you get early and late responders and this makes a difference to long-term outcomes.”

New data from the COMET trial, a two-year study of Pfizer's Enbrel (etanercept) and methotrexate versus methotrexate alone in early moderate to severe rheumatoid arthritis, showed that a greater proportion of patients treated with the combination regimen within four months of diagnosis achieved clinical remission compared to patients treated after at least four months following diagnosis. Prof Emery, professor of rheumatology at the University of Leeds, said: “These data provide further evidence of the importance of intervening early in RA. Furthermore, evidence of the importance of TNF in the pathogenesis in the early phase of disease and the qualitative better outcomes that occurs with combination therapy which is not seen with MTX alone suggesting optimal time for TNF blockade to be used. Early intervention, frequent monitoring of treatment response and management aimed at treating RA to a target of remission or low disease activity should be the guiding principles of RA management.”

The COMET data showed that nearly 70% of the 63 RA patients treated very early (within four months of diagnosis) with etanercept and methotrexate achieved remission compared with nearly 48% treated with the combination regimen early (after four months). Only 35% of the very early treated patients with methotrexate alone achieved remission and only 32% of the early treated patients with methotrexate alone achieved remission. By Rhonda Siddall