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The Utrecht experience with different treatment strategies in early rheumatoid arthritis.

Since 1990 the Utrecht Rheumatoid Arthritis Cohort study group has performed several clinical trials on different treatment strategies in early rheumatoid arthritis (RA) patients. From 1990 till 1994, patients were randomly assigned to the pyramid strategy group or the early DMARD group. Patients in the early DMARD group were allocated to one of the three following treatment strategies: strategy I, starting with hydroxychloroquine (HCQ); strategy II, starting with intramuscular gold (iAU); or strategy III, starting with oral methotrexate (MTX). After one year, statistically significant advantages for the early DMARD group compared with the pyramid group were found for disability, pain, joint score, and ESR. The increase in radiological damage did not differ significantly between the two strategy groups. These first year results proved that early introduction of DMARDs is more beneficial than a delayed introduction. After 5 years, however, no prolongation of the clinical advantages in favor of the early DMARD group, as observed after one year, was found. It was found that patients assigned to the pyramid group received more intra-articular injections during the first two years; at the end of this period 75% of them used DMARDs, especially the more aggressive DMARDs. Based on the first year results, all patients were randomly assigned to one of the three treatment strategies in the early DMARD group between 1994 and 1998. Patients who started with MTX or iAU as the first DMARD demonstrated better results regarding clinical efficacy and radiological damage after 2 years. However, more patients who received iAU therapy had to discontinue their therapy compared with patients who took MTX. We therefore conclude that MTX is the DMARD of first choice and that treatment should be tailored to the individual patient.

Adult↗
PubMed2004

[Ct findings of drug-induced pneumonitis--characteristic CT findings by histological group and subgroup].

We examined the chest CT results of 27 cases of drug-induced pneumonitis. We classified the subjects into 3 groups in accordance with the clinicopathological findings: eosinophilic pneumonia (EP) group (5 cases), diffuse alveolar damage (DAD) group (3 cases), and interstitial pneumonia (IP) group (19 cases). We evaluated the CT findings in each group, and made a further subclassification. In the EP group, the CT findings were subdivided into two, namely, type A, with diffuse distribution consistent with CT findings of acute eosinophilic pneumonia; and type B, with subpleural distribution consistent with chronic eosinophilic pneumonia. In the DAD group, the CT findings were diffuse distribution of mixed ground-glass attenuation and air-space consolidation, with or without traction bronchiectasis, and without shrinking of the lung. In the IP group, the CT findings were subdivided into 3, namely type A, with ground-glass attenuation dominant, without traction bronchiectasis or shrinking of the lung, consistent with the CT findings of IP without fibrosis; type B, with air-space consolidation dominant, with traction bronchiectasis and shrinking of the lung, consistent with the CT findings of IP with fibrosis; and type C with multiple nodules dominant. Radiological differentiation of the DAD group from IP-type B may be possible by the presence or absence of a shrinking lung pattern. We concluded that the subgroups of CT findings in drug-induced pneumonitis may be useful for diagnosis of this disease, and for prognosis.

Adult↗
PubMed2004

Criteria for improvement in rheumatoid arthritis: alternatives to the American College of Rheumatology 20.

OBJECTIVE: Appropriate outcome measures are critical to estimating treatment effects in clinical trials and observational studies. The American College of Rheumatology 20 (ACR 20) is the standard measure to assess treatment effects in rheumatoid arthritis (RA) randomized controlled clinical trials (RCT). Although the ACR 20, which measures at least a 20% improvement in a number of different measures, is a very useful dichotomous measure for identifying novel treatments with potential activity, it may fail to discriminate among active treatments. In an effort to increase stringency, trials have used the ACR at 50% and 70%. We investigated the behavior of these and other scoring systems to quantify treatment outcome in several RCT in RA. METHODS: The Cooperating Clinics for the Systematic Study of Rheumatic Disease (CSSRD) database contained 2 trials with a total of 6 arms. Using raw data for each patient entered, we calculated ACR 20, 50, and 70 for each arm. We also calculated the average number of criteria met for the ACR 20, 50, and 70 and their respective areas under the curve over time. RESULTS: The ACR 20 failed to discriminate among active therapies; however, the ACR 50 was too stringent, and only one patient in these trials satisfied the ACR 70. The average number of criteria satisfied at the 50% level at the final trial visit discriminated well, as did the area under the curve. CONCLUSION: The average number of ACR criteria met at a 20% or 50% level discriminated better than the traditional ACR criteria in these trials. More of the information is preserved by the area under the curve of the number of ACR criteria satisfied at each level because area preserves both the number of criteria and the time dependence. The area under the curve of the number of ACR criteria met is a discriminatory, specific, time-dependent, responsive, and domain-preserving metric to use as the primary outcome measure in trials of agents for the treatment of RA. These conclusions should be tested in additional data sets.

Antirheumatic Agents↗
PubMed2004

[Markov model of decision making for basic therapy of rheumatoid arthritis: oder of monotherapy and expenses for drug therapy].

AIM: To design Markov's model of decision making to study the role of order in the use of most usable basic antirheumatic drugs (methotrexate-MT, parenteral gold--PG and sulfasalasine--SS) in terms of the course duration and cost. MATERIAL AND METHODS: The model was based on metaanalysis made in 2000. The program TreeAge 3.0 was used. The prices for the drugs were taken as mean about Moscow for 2002 and prices presented by ACR for 2002. RESULTS: The sequence MT-PG-SS had the advantage over the other sequences in that less number of patients stopped treatment after 5 and 10 years of therapy. Mean cost of the drugs per patient is the lowest (for five years) if MT is prescribed first. In longer treatment SS-MT-PG is more cost-effective. CONCLUSION: It is feasible to design Markov's models for making decision on optimal therapy of rheumatoid arthritis both in terms of cost and clinical response.

Antirheumatic Agents↗