Early, intensive treatment of RA offers long-term benefits, may normalise mortality rates

The results of a 23-year, follow-up study presented today at the Annual European Congress of Rheumatology (EULAR 2018) suggest early, intensive treatment of rheumatoid arthritis has long-term benefits including the normalisation of mortality to levels consistent with the general population.

"We know that the adverse effects of rheumatoid arthritis on the body only become truly apparent after more than a decade," said Professor Robert Landewé, Chairperson of the Scientific Programme Committee, EULAR. "Therefore, it is really interesting to see these data supporting early therapy after such a long period of follow-up."

Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects a person's joints, causing pain and disability. It can also affect internal organs. Rheumatoid arthritis is more common in older people, but there is also a high prevalence in young adults, adolescents and even children, and it affects women more frequently than men.

Mortality in patients with RA is higher than in the general population. There have been many advances in management which have demonstrated improved morbidity rates, however evidence of improved mortality rates has remained elusive.

"Our results confirm that early, intensive treatment of rheumatoid arthritis, including use of glucocorticoids, has long-term benefits", said Professor Maarten Boers, VU University Medical Center, Amsterdam, The Netherlands (study author). "Importantly, this study is one of the first to show a normalisation of RA mortality compared to the general population after 23 years of follow-up."

This prospective study looked at the rate of mortality after 23 years follow-up of the COBRA (COmbinatietherapie Bij Rheumatoide Artritis) trial. In the original study, patients with early RA were treated with sulphalasazine (SSZ) monotherapy or a combination of SSZ, low-dose methotrexate and initially high, step-down prednisolone. Results demonstrated the combined therapy regimen offered additional disease control over SSZ alone. In 2010, after 11 years of follow up, another study showed numerically (but not significantly) lower mortality in patients on the combined therapy regimen compared to patients with SSZ monotherapy.

The current study included data from 154 of the 155 original patients with a mean follow-up time of 23 years (in those that did not die). Using a reference sample matched for age and gender, investigators demonstrated numerically (but not significantly) lower mortality of the study participants (44/154, 28%) compared to the general population (55/154, 35%). Within the study population, 20/75 (27%) died who were randomised to the combined therapy regimen, and 24/79 (30%) on SSZ alone. The difference between the two therapeutic approaches was not significant and the positive trend for combined therapy over SSZ decreased over time.