If your approach to rheumatoid arthritis (RA) is “start low, go slow” because of concerns about drug toxicities and overtreatment, you may be too cautious. A large Dutch study shows that early, intense therapy gives patients better results than a gradual, step-up strategy.

Clinicians at multiple sites in the Netherlands randomly assigned 508 adults with median RA duration of 23 weeks to one of four groups: (1) sequential disease-modifying antirheumatic drug (DMARD) monotherapy, (2) step-up to a combination of three DMARDs, (3) methotrexate, sulfasalazine, and tapered, high-dose prednisone, and (4) methotrexate combined with infliximab (Remicade). Treatment adjustments were made at three-month intervals to maintain tight control.

In all four groups, 29%-36% of patients achieved clinical remission (disease activity score <1.6) after a year, which increased to 38%-46% after the second year. But during the first year, patients on combination therapy (groups 3 and 4) achieved lower levels of disease activity than did those in groups 1 and 2.

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Patients in groups 3 and 4 also had less radiographic progression of joint damage after two years. In addition, severe progression was seen less often in groups 3 and 4 than in groups 1 and 2 (Ann Intern Med. 2007; 146:406-415).

James R. O’Dell, MD, an internist at the University of Nebraska Medical Center in Omaha, opines that “with the ever-increasing complexity, expense, and toxicity of modern therapy,” primary-care clinicians should involve a rheumatologist when treating arthritis patients. He added that all patients should receive methotrexate or another disease-modifying drug as early as possible (Ann Intern Med. 2007;146:459-460).