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Early aggressive therapy in rheumatoid arthritis: a 'window of opportunity'?

Nature Clinical Practice Rheumatology volume 1, pages 2–3 (2005)Cite this article

Rheumatoid arthritis (RA) is characterized by the acquisition of certain phenotypic characteristics, including joint destruction and extra-articular features. Although the molecular basis of disease progression in RA is still unknown, there is accumulating evidence that appropriate therapy might prevent the development of a detrimental RA phenotype and have a positive impact on long-term outcome. Intervention studies have suggested that therapy should be initiated in the early stages of disease in order to reduce disease activity most effectively.1 Other studies have shown that supposedly important pathophysiologic processes, such as the generation of autoantibody responses, might occur before clinical presentation of the disease, thereby providing tools for diagnostic tests. With regard to the timing of treatment in RA, it has become clear that not only can symptoms be rapidly relieved by early treatment, but structural damage can also be prevented.

Studies specifically comparing the timing of treatment initiation and its impact on disease duration are relatively scarce. Valuable data were obtained in a 5-year follow-up study by Egsmose et al.,2 in which early treatment with intramuscular gold was compared with a delayed-treatment strategy. The early-treatment group showed improvement with respect to signs and symptoms, physical function and radiographic progression, thereby supporting the hypothesis that a therapeutic 'window of opportunity' exists. In another trial by van der Heide et al.,3 immediate and delayed introduction of disease-modifying antirheumatic drug (DMARD) therapy were compared in patients with recently diagnosed RA. Early introduction of DMARDs resulted in patient improvement with regards to signs and symptoms, physical function and radiographic progression. The conventional pyramid strategy, consisting of sequential initiation of nonsteroidal anti-inflammatory drugs and subsequent DMARD therapy, was compared with immediate initiation of DMARD therapy in an observational study by van Aken and colleagues: again, the early treatment group showed reduced radiographic progression.4 Finally, an observational study performed at the Norfolk Arthritis Register provided evidence that patients in whom DMARD therapy was initiated within 6 months of diagnosis of RA had a better 5-year radiographic outcome than patients starting DMARD therapy 6 months after RA diagnosis.5

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Authors and Affiliations

  1. Professor of Rheumatology in the Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands

    Tom WJ Huizinga

  2. RBM Landewé is an Associate Professor in the Department of Rheumatology, University Hospital Maastricht, Maastricht, The Netherlands

    Robert BM Landewé

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  1. Tom WJ Huizinga
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  2. Robert BM Landewé
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Correspondence to Tom WJ Huizinga.

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The authors declare no competing financial interests.

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Huizinga, T., Landewé, R. Early aggressive therapy in rheumatoid arthritis: a 'window of opportunity'?. Nat Rev Rheumatol 1, 2–3 (2005). https://doi.org/10.1038/ncprheum0015

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