The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study
Identifieur interne : 002976 ( Istex/Corpus ); précédent : 002975; suivant : 002977The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study
Auteurs : Naomi B. Klarenbeek ; Melek Güler-Yüksel ; Sjoerd M. Van Der Kooij ; K Huub Han ; H Karel Ronday ; Pit J S M. Kerstens ; Patrick E H. Seys ; Tom W J. Huizinga ; Ben A C. Dijkmans ; Cornelia F. AllaartSource :
- Annals of the Rheumatic Diseases [ 0003-4967 ] ; 2011-06.
English descriptors
- Teeft :
- Adverse event, Adverse events, American college, American rheumatism association, Annual progression, Antirheumatic drugs, Arthritis, Arthritis rheum, Available drugs, Baseline, Best study, Breemen institute, Bronovo hospital, Cerebrovascular accident, Clinical improvement, Clinical outcomes, Clinical practice, Clinical remission, Clinical response, Combination therapy, Comparable level, Covariance matrix, Damage progression, Disease activity, Disease activity score, Drugfree remission, Dynamic treatment, Dynamic treatment strategies, Franciscus hospital, Functional ability, Functional capacity, Gasthuis, General population, Graaf gasthuis, Groene hart hospital, Gure, Haga hospital, Health assessment questionnaire, Health survey, Heijde score, Impressive improvement, Initial combination, Initial combination therapy, Initial combination therapy groups, Initial monotherapy, Initial monotherapy groups, Initial treatment, Joint damage, Joint damage progression, Kennemer gasthuis, Last dmard, Latent tuberculosis, Leiden university, Maintenance dose, Medical center, Medical center haaglanden, Mental component scale, Methotrexate, Monotherapy, Monotherapy drop outs, More toxicity, Myocardial infarction, Next treatment step, Other comparisons, Physical component scale, Pred, Pred gold, Prednisone, Progression, Radiological, Radiological outcomes, Reference population, Remission, Remission percentages, Rheum, Rheumatoid, Rheumatoid arthritis, Rheumatoid factor, Rheumatologist, Rheumatology, Rheumatology research, Ruyter hospital, Sequential, Sequential monotherapy, Sint franciscus gasthuis, Spaarne hospital, Study design, Study protocol, Supplementary table, Treatment adjustments, Treatment group, Treatment groups, Treatment step, Treatment strategies, Vlietland hospital.
Abstract
Objective To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up. Methods 508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS <1.6 during ≥6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages. Results After 5 years, 48% of patients were in clinical remission (DAS <1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2–5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response. Conclusion Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.
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DOI: 10.1136/ard.2010.141234
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Klarenbeek</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Guler Yuksel, Melek" sort="Guler Yuksel, Melek" uniqKey="Guler Yuksel M" first="Melek" last="Güler-Yüksel">Melek Güler-Yüksel</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Van Der Kooij, Sjoerd M" sort="Van Der Kooij, Sjoerd M" uniqKey="Van Der Kooij S" first="Sjoerd M" last="Van Der Kooij">Sjoerd M. Van Der Kooij</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Han, K Huub" sort="Han, K Huub" uniqKey="Han K" first="K Huub" last="Han">K Huub Han</name><affiliation><mods:affiliation>Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Ronday, H Karel" sort="Ronday, H Karel" uniqKey="Ronday H" first="H Karel" last="Ronday">H Karel Ronday</name><affiliation><mods:affiliation>Department of Rheumatology, Haga Hospital, The Hague, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Kerstens, Pit J S M" sort="Kerstens, Pit J S M" uniqKey="Kerstens P" first="Pit J S M" last="Kerstens">Pit J S M. Kerstens</name><affiliation><mods:affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Seys, Patrick E H" sort="Seys, Patrick E H" uniqKey="Seys P" first="Patrick E H" last="Seys">Patrick E H. Seys</name><affiliation><mods:affiliation>Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Huizinga, Tom W J" sort="Huizinga, Tom W J" uniqKey="Huizinga T" first="Tom W J" last="Huizinga">Tom W J. Huizinga</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Dijkmans, Ben A C" sort="Dijkmans, Ben A C" uniqKey="Dijkmans B" first="Ben A C" last="Dijkmans">Ben A C. Dijkmans</name><affiliation><mods:affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</mods:affiliation></affiliation><affiliation><mods:affiliation>Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Allaart, Cornelia F" sort="Allaart, Cornelia F" uniqKey="Allaart C" first="Cornelia F" last="Allaart">Cornelia F. Allaart</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:13B207CBF804CAEE46AE02E9D5AF73B776C4F230</idno><date when="2011" year="2011">2011</date><idno type="doi">10.1136/ard.2010.141234</idno><idno type="url">https://api.istex.fr/ark:/67375/NVC-2ZWQGB8D-T/fulltext.pdf</idno><idno type="wicri:Area/Istex/Corpus">002976</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">002976</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a">The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study</title><author><name sortKey="Klarenbeek, Naomi B" sort="Klarenbeek, Naomi B" uniqKey="Klarenbeek N" first="Naomi B" last="Klarenbeek">Naomi B. Klarenbeek</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Guler Yuksel, Melek" sort="Guler Yuksel, Melek" uniqKey="Guler Yuksel M" first="Melek" last="Güler-Yüksel">Melek Güler-Yüksel</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Van Der Kooij, Sjoerd M" sort="Van Der Kooij, Sjoerd M" uniqKey="Van Der Kooij S" first="Sjoerd M" last="Van Der Kooij">Sjoerd M. Van Der Kooij</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Han, K Huub" sort="Han, K Huub" uniqKey="Han K" first="K Huub" last="Han">K Huub Han</name><affiliation><mods:affiliation>Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Ronday, H Karel" sort="Ronday, H Karel" uniqKey="Ronday H" first="H Karel" last="Ronday">H Karel Ronday</name><affiliation><mods:affiliation>Department of Rheumatology, Haga Hospital, The Hague, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Kerstens, Pit J S M" sort="Kerstens, Pit J S M" uniqKey="Kerstens P" first="Pit J S M" last="Kerstens">Pit J S M. Kerstens</name><affiliation><mods:affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Seys, Patrick E H" sort="Seys, Patrick E H" uniqKey="Seys P" first="Patrick E H" last="Seys">Patrick E H. Seys</name><affiliation><mods:affiliation>Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Huizinga, Tom W J" sort="Huizinga, Tom W J" uniqKey="Huizinga T" first="Tom W J" last="Huizinga">Tom W J. Huizinga</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Dijkmans, Ben A C" sort="Dijkmans, Ben A C" uniqKey="Dijkmans B" first="Ben A C" last="Dijkmans">Ben A C. Dijkmans</name><affiliation><mods:affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</mods:affiliation></affiliation><affiliation><mods:affiliation>Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands</mods:affiliation></affiliation></author><author><name sortKey="Allaart, Cornelia F" sort="Allaart, Cornelia F" uniqKey="Allaart C" first="Cornelia F" last="Allaart">Cornelia F. Allaart</name><affiliation><mods:affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Annals of the Rheumatic Diseases</title><title level="j" type="abbrev">Ann Rheum Dis</title><idno type="ISSN">0003-4967</idno><idno type="eISSN">1468-2060</idno><imprint><publisher>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><date type="published" when="2011-06">2011-06</date><biblScope unit="volume">70</biblScope><biblScope unit="issue">6</biblScope><biblScope unit="page" from="1039">1039</biblScope></imprint><idno type="ISSN">0003-4967</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0003-4967</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="Teeft" xml:lang="en"><term>Adverse event</term><term>Adverse events</term><term>American college</term><term>American rheumatism association</term><term>Annual progression</term><term>Antirheumatic drugs</term><term>Arthritis</term><term>Arthritis rheum</term><term>Available drugs</term><term>Baseline</term><term>Best study</term><term>Breemen institute</term><term>Bronovo hospital</term><term>Cerebrovascular accident</term><term>Clinical improvement</term><term>Clinical outcomes</term><term>Clinical practice</term><term>Clinical remission</term><term>Clinical response</term><term>Combination therapy</term><term>Comparable level</term><term>Covariance matrix</term><term>Damage progression</term><term>Disease activity</term><term>Disease activity score</term><term>Drugfree remission</term><term>Dynamic treatment</term><term>Dynamic treatment strategies</term><term>Franciscus hospital</term><term>Functional ability</term><term>Functional capacity</term><term>Gasthuis</term><term>General population</term><term>Graaf gasthuis</term><term>Groene hart hospital</term><term>Gure</term><term>Haga hospital</term><term>Health assessment questionnaire</term><term>Health survey</term><term>Heijde score</term><term>Impressive improvement</term><term>Initial combination</term><term>Initial combination therapy</term><term>Initial combination therapy groups</term><term>Initial monotherapy</term><term>Initial monotherapy groups</term><term>Initial treatment</term><term>Joint damage</term><term>Joint damage progression</term><term>Kennemer gasthuis</term><term>Last dmard</term><term>Latent tuberculosis</term><term>Leiden university</term><term>Maintenance dose</term><term>Medical center</term><term>Medical center haaglanden</term><term>Mental component scale</term><term>Methotrexate</term><term>Monotherapy</term><term>Monotherapy drop outs</term><term>More toxicity</term><term>Myocardial infarction</term><term>Next treatment step</term><term>Other comparisons</term><term>Physical component scale</term><term>Pred</term><term>Pred gold</term><term>Prednisone</term><term>Progression</term><term>Radiological</term><term>Radiological outcomes</term><term>Reference population</term><term>Remission</term><term>Remission percentages</term><term>Rheum</term><term>Rheumatoid</term><term>Rheumatoid arthritis</term><term>Rheumatoid factor</term><term>Rheumatologist</term><term>Rheumatology</term><term>Rheumatology research</term><term>Ruyter hospital</term><term>Sequential</term><term>Sequential monotherapy</term><term>Sint franciscus gasthuis</term><term>Spaarne hospital</term><term>Study design</term><term>Study protocol</term><term>Supplementary table</term><term>Treatment adjustments</term><term>Treatment group</term><term>Treatment groups</term><term>Treatment step</term><term>Treatment strategies</term><term>Vlietland hospital</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract">Objective To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up. Methods 508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS <1.6 during ≥6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages. Results After 5 years, 48% of patients were in clinical remission (DAS <1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2–5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response. Conclusion Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.</div></front></TEI><istex><corpusName>bmj</corpusName><keywords><teeft><json:string>remission</json:string><json:string>monotherapy</json:string><json:string>rheumatoid</json:string><json:string>rheumatoid arthritis</json:string><json:string>pred</json:string><json:string>rheumatology</json:string><json:string>combination therapy</json:string><json:string>methotrexate</json:string><json:string>rheum</json:string><json:string>radiological</json:string><json:string>disease activity</json:string><json:string>sequential</json:string><json:string>gure</json:string><json:string>initial combination</json:string><json:string>gasthuis</json:string><json:string>treatment groups</json:string><json:string>treatment strategies</json:string><json:string>arthritis</json:string><json:string>functional ability</json:string><json:string>joint damage progression</json:string><json:string>rheumatologist</json:string><json:string>initial combination therapy</json:string><json:string>progression</json:string><json:string>initial treatment</json:string><json:string>baseline</json:string><json:string>damage progression</json:string><json:string>treatment adjustments</json:string><json:string>best study</json:string><json:string>radiological outcomes</json:string><json:string>initial monotherapy groups</json:string><json:string>disease activity score</json:string><json:string>joint damage</json:string><json:string>dynamic treatment</json:string><json:string>sequential monotherapy</json:string><json:string>groene hart hospital</json:string><json:string>clinical remission</json:string><json:string>haga hospital</json:string><json:string>arthritis rheum</json:string><json:string>adverse events</json:string><json:string>remission percentages</json:string><json:string>antirheumatic drugs</json:string><json:string>initial monotherapy</json:string><json:string>cerebrovascular accident</json:string><json:string>sint franciscus gasthuis</json:string><json:string>other comparisons</json:string><json:string>covariance matrix</json:string><json:string>general population</json:string><json:string>kennemer gasthuis</json:string><json:string>clinical response</json:string><json:string>initial combination therapy groups</json:string><json:string>medical center</json:string><json:string>bronovo hospital</json:string><json:string>monotherapy drop outs</json:string><json:string>american college</json:string><json:string>reference population</json:string><json:string>mental component scale</json:string><json:string>prednisone</json:string><json:string>study protocol</json:string><json:string>last dmard</json:string><json:string>rheumatoid factor</json:string><json:string>rheumatology research</json:string><json:string>treatment group</json:string><json:string>drugfree remission</json:string><json:string>treatment step</json:string><json:string>more toxicity</json:string><json:string>health assessment questionnaire</json:string><json:string>clinical improvement</json:string><json:string>impressive improvement</json:string><json:string>functional capacity</json:string><json:string>comparable level</json:string><json:string>annual progression</json:string><json:string>heijde score</json:string><json:string>clinical outcomes</json:string><json:string>adverse event</json:string><json:string>latent tuberculosis</json:string><json:string>pred gold</json:string><json:string>maintenance dose</json:string><json:string>myocardial infarction</json:string><json:string>available drugs</json:string><json:string>next treatment step</json:string><json:string>study design</json:string><json:string>medical center haaglanden</json:string><json:string>physical component scale</json:string><json:string>graaf gasthuis</json:string><json:string>vlietland hospital</json:string><json:string>dynamic treatment strategies</json:string><json:string>ruyter hospital</json:string><json:string>spaarne hospital</json:string><json:string>franciscus hospital</json:string><json:string>breemen institute</json:string><json:string>leiden university</json:string><json:string>supplementary table</json:string><json:string>clinical practice</json:string><json:string>american rheumatism association</json:string><json:string>health survey</json:string></teeft></keywords><author><json:item><name>Naomi B Klarenbeek</name><affiliations><json:string>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</json:string></affiliations></json:item><json:item><name>Melek Güler-Yüksel</name><affiliations><json:string>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</json:string></affiliations></json:item><json:item><name>Sjoerd M van der Kooij</name><affiliations><json:string>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</json:string></affiliations></json:item><json:item><name>K Huub Han</name><affiliations><json:string>Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands</json:string></affiliations></json:item><json:item><name>H Karel Ronday</name><affiliations><json:string>Department of Rheumatology, Haga Hospital, The Hague, The Netherlands</json:string></affiliations></json:item><json:item><name>Pit J S M Kerstens</name><affiliations><json:string>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</json:string></affiliations></json:item><json:item><name>Patrick E H Seys</name><affiliations><json:string>Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands</json:string></affiliations></json:item><json:item><name>Tom W J Huizinga</name><affiliations><json:string>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</json:string></affiliations></json:item><json:item><name>Ben A C Dijkmans</name><affiliations><json:string>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</json:string><json:string>Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands</json:string></affiliations></json:item><json:item><name>Cornelia F Allaart</name><affiliations><json:string>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</json:string></affiliations></json:item></author><articleId><json:string>annrheumdis141234</json:string></articleId><arkIstex>ark:/67375/NVC-2ZWQGB8D-T</arkIstex><language><json:string>eng</json:string></language><originalGenre><json:string>research-article</json:string></originalGenre><abstract>Objective To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up. Methods 508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS >1.6 during ≥6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages. Results After 5 years, 48% of patients were in clinical remission (DAS >1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2–5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response. Conclusion Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.</abstract><qualityIndicators><score>9.976</score><pdfWordCount>5085</pdfWordCount><pdfCharCount>33672</pdfCharCount><pdfVersion>1.6</pdfVersion><pdfPageCount>8</pdfPageCount><pdfPageSize>595.277 x 793.702 pts</pdfPageSize><refBibsNative>true</refBibsNative><abstractWordCount>248</abstractWordCount><abstractCharCount>1809</abstractCharCount><keywordCount>0</keywordCount></qualityIndicators><title>The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study</title><pmid><json:string>21415052</json:string></pmid><genre><json:string>research-article</json:string></genre><host><title>Annals of the Rheumatic Diseases</title><language><json:string>unknown</json:string></language><issn><json:string>0003-4967</json:string></issn><eissn><json:string>1468-2060</json:string></eissn><publisherId><json:string>ard</json:string></publisherId><volume>70</volume><issue>6</issue><pages><first>1039</first></pages><genre><json:string>journal</json:string></genre></host><namedEntities><unitex><date><json:string>5</json:string><json:string>1990s</json:string><json:string>1</json:string><json:string>1987</json:string><json:string>2</json:string><json:string>2011-03-17</json:string><json:string>Between March 2000 and August 2002</json:string><json:string>3</json:string></date><geogName></geogName><orgName><json:string>Hospital, Terneuzen</json:string><json:string>Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands</json:string><json:string>Spaarne Hospital, Hoofddorp</json:string><json:string>Ruyter Hospital, Goes</json:string><json:string>Medical Center</json:string><json:string>VU Medical Center, Amsterdam</json:string><json:string>Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands</json:string><json:string>Albert Schweitzer Hospital, Dordrecht</json:string><json:string>Department of Rheumatology, Haga Hospital, The Hague, The Netherlands</json:string><json:string>Haga Hospital, The Hague</json:string><json:string>Department of Rheumatology</json:string><json:string>Groene Hart Hospital, Gouda</json:string><json:string>Medical Center Haaglanden, The Hague</json:string><json:string>Bronovo Hospital, The Hague</json:string><json:string>Breemen Institute, Amsterdam</json:string><json:string>Ruyter Hospital, Vlissingen</json:string><json:string>Vlietland Hospital, Schiedam</json:string><json:string>Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands Correspondence</json:string><json:string>Department of Rheumatology, Jan</json:string><json:string>Leiden University</json:string><json:string>Foundation for Applied Rheumatology Research</json:string><json:string>Franciscus Hospital, Roosendaal</json:string><json:string>Breemen Institute, Amsterdam, The Netherlands</json:string><json:string>Erasmus Medical Center, Rotterdam</json:string><json:string>American College of Rheumatology</json:string><json:string>Schering-Plough Ltd.</json:string><json:string>Slotervaart Hospital, Amsterdam</json:string></orgName><orgName_funder></orgName_funder><orgName_provider></orgName_provider><persName><json:string>R.M. van Soesbergen</json:string><json:string>R.J. Goekoop</json:string><json:string>H.M.J. Hulsmans</json:string><json:string>T.H.E. Molenaar</json:string><json:string>A.A. Schouffour</json:string><json:string>Ann Rheum</json:string><json:string>M.V. van Krugten</json:string><json:string>I. Speyer</json:string><json:string>J.Ph</json:string><json:string>Karel Ronday</json:string><json:string>P.B.J. de Sonnaville</json:string><json:string>C. Bijkerk</json:string><json:string>B.A.M. Grillet</json:string><json:string>M.H. de Jager</json:string><json:string>J.H.L.M. van Groenendael</json:string><json:string>D. van Schaardenburg</json:string><json:string>G. Collée</json:string><json:string>A.J. Peeters</json:string><json:string>D. van Zeben</json:string><json:string>K.S.S. Steen</json:string><json:string>H. van der Leeden</json:string><json:string>W.M. de Beus</json:string><json:string>M.H.W. de Bois</json:string><json:string>H.K. Markusse</json:string><json:string>C. Mallée</json:string><json:string>J.M. de Jonge-Bok</json:string><json:string>M. van Oosterhout</json:string><json:string>Extended</json:string><json:string>H.C. van Paassen</json:string><json:string>G.M. SteupBeekman</json:string><json:string>A.E. Voskuyl</json:string><json:string>J.M.G.W. Wouters</json:string><json:string>Melek Güler-Yüksel</json:string><json:string>M.L. Westedt</json:string><json:string>A.H. Gerards</json:string><json:string>A. Linssen</json:string><json:string>J.A.P.M. Ewals</json:string><json:string>P.A.H.M. van der Lubbe</json:string><json:string>M.F. van Lieshout-Zuidema</json:string><json:string>W.F. Lems</json:string><json:string>J.M.W. Hazes</json:string></persName><placeName><json:string>Haarlem</json:string><json:string>Rotterdam</json:string><json:string>Netherlands</json:string></placeName><ref_url><json:string>http://ard.bmj.com</json:string></ref_url><ref_bibl></ref_bibl><bibl></bibl></unitex></namedEntities><ark><json:string>ark:/67375/NVC-2ZWQGB8D-T</json:string></ark><categories><wos><json:string>1 - science</json:string><json:string>2 - rheumatology</json:string></wos><scienceMetrix><json:string>1 - health sciences</json:string><json:string>2 - clinical medicine</json:string><json:string>3 - arthritis & rheumatology</json:string></scienceMetrix><scopus><json:string>1 - Life Sciences</json:string><json:string>2 - Biochemistry, Genetics and Molecular Biology</json:string><json:string>3 - General Biochemistry, Genetics and Molecular Biology</json:string><json:string>1 - Life Sciences</json:string><json:string>2 - Immunology and Microbiology</json:string><json:string>3 - Immunology</json:string><json:string>1 - Health Sciences</json:string><json:string>2 - Medicine</json:string><json:string>3 - Immunology and Allergy</json:string><json:string>1 - Health Sciences</json:string><json:string>2 - Medicine</json:string><json:string>3 - Rheumatology</json:string></scopus><inist><json:string>1 - sciences appliquees, technologies et medecines</json:string><json:string>2 - sciences biologiques et medicales</json:string><json:string>3 - sciences medicales</json:string></inist></categories><publicationDate>2011</publicationDate><copyrightDate>2011</copyrightDate><doi><json:string>10.1136/ard.2010.141234</json:string></doi><id>13B207CBF804CAEE46AE02E9D5AF73B776C4F230</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-2ZWQGB8D-T/fulltext.pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-2ZWQGB8D-T/bundle.zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/ark:/67375/NVC-2ZWQGB8D-T/fulltext.tei"><teiHeader><fileDesc><titleStmt><title level="a">The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher scheme="https://publisher-list.data.istex.fr">BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><availability><licence><p>Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions</p></licence><p scheme="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-7M42M2QJ-2">bmj</p></availability><date>2011-03-17</date></publicationStmt><notesStmt><note type="research-article" scheme="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</note><note type="journal" scheme="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a">The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study</title><author xml:id="author-0000"><persName><forename type="first">Naomi B</forename><surname>Klarenbeek</surname></persName><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation></author><author xml:id="author-0001"><persName><forename type="first">Melek</forename><surname>Güler-Yüksel</surname></persName><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Sjoerd M</forename><surname>van der Kooij</surname></persName><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation></author><author xml:id="author-0003"><persName><forename type="first">K Huub</forename><surname>Han</surname></persName><affiliation>Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands</affiliation></author><author xml:id="author-0004"><persName><forename type="first">H Karel</forename><surname>Ronday</surname></persName><affiliation>Department of Rheumatology, Haga Hospital, The Hague, The Netherlands</affiliation></author><author xml:id="author-0005"><persName><forename type="first">Pit J S M</forename><surname>Kerstens</surname></persName><affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</affiliation></author><author xml:id="author-0006"><persName><forename type="first">Patrick E H</forename><surname>Seys</surname></persName><affiliation>Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands</affiliation></author><author xml:id="author-0007"><persName><forename type="first">Tom W J</forename><surname>Huizinga</surname></persName><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation></author><author xml:id="author-0008"><persName><forename type="first">Ben A C</forename><surname>Dijkmans</surname></persName><affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</affiliation><affiliation>Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands</affiliation></author><author xml:id="author-0009"><persName><forename type="first">Cornelia F</forename><surname>Allaart</surname></persName><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation></author><idno type="istex">13B207CBF804CAEE46AE02E9D5AF73B776C4F230</idno><idno type="ark">ark:/67375/NVC-2ZWQGB8D-T</idno><idno type="DOI">10.1136/ard.2010.141234</idno><idno type="href">annrheumdis-70-1039.pdf</idno><idno type="article-id">annrheumdis141234</idno><idno type="PMID">21415052</idno><idno type="local">annrheumdis;70/6/1039</idno></analytic><monogr><title level="j">Annals of the Rheumatic Diseases</title><title level="j" type="abbrev">Ann Rheum Dis</title><idno type="pISSN">0003-4967</idno><idno type="eISSN">1468-2060</idno><idno type="publisher-id">ard</idno><idno type="PublisherID-hwp">annrheumdis</idno><idno type="PublisherID-nlm-ta">Ann Rheum Dis</idno><imprint><publisher>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><date type="published" when="2011-06"></date><biblScope unit="volume">70</biblScope><biblScope unit="issue">6</biblScope><biblScope unit="page" from="1039">1039</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2011-03-17</date></creation><langUsage><language ident="en">en</language></langUsage><abstract><p>Objective To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up. Methods 508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS <1.6 during ≥6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages. Results After 5 years, 48% of patients were in clinical remission (DAS <1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2–5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response. Conclusion Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.</p></abstract></profileDesc><revisionDesc><change when="2011-03-17">Created</change><change when="2011-06">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-2ZWQGB8D-T/fulltext.txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus bmj" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8" standalone="no"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Archiving and Interchange DTD v2.3 20070202//EN" URI="archivearticle.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="research-article"><front><journal-meta><journal-id journal-id-type="hwp">annrheumdis</journal-id><journal-id journal-id-type="nlm-ta">Ann Rheum Dis</journal-id><journal-id journal-id-type="publisher-id">ard</journal-id><journal-title>Annals of the Rheumatic Diseases</journal-title><abbrev-journal-title abbrev-type="publisher">Ann Rheum Dis</abbrev-journal-title><abbrev-journal-title>Ann Rheum Dis</abbrev-journal-title><issn pub-type="ppub">0003-4967</issn><issn pub-type="epub">1468-2060</issn><publisher><publisher-name>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="publisher-id">annrheumdis141234</article-id><article-id pub-id-type="doi">10.1136/ard.2010.141234</article-id><article-id pub-id-type="other">annrheumdis;70/6/1039</article-id><article-id pub-id-type="other">annrheumdis;ard.2010.141234</article-id><article-id pub-id-type="pmid">21415052</article-id><article-id pub-id-type="other">1039</article-id><article-id pub-id-type="other">ard.2010.141234</article-id><article-categories><subj-group subj-group-type="heading"><subject>Clinical and epidemiological research</subject></subj-group><series-title>Extended report</series-title></article-categories><title-group><article-title>The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Klarenbeek</surname><given-names>Naomi B</given-names></name><xref ref-type="aff" rid="A1">1</xref></contrib><contrib contrib-type="author"><name><surname>Güler-Yüksel</surname><given-names>Melek</given-names></name><xref ref-type="aff" rid="A1">1</xref></contrib><contrib contrib-type="author"><name><surname>van der Kooij</surname><given-names>Sjoerd M</given-names></name><xref ref-type="aff" rid="A1">1</xref></contrib><contrib contrib-type="author"><name><surname>Han</surname><given-names>K Huub</given-names></name><xref ref-type="aff" rid="A2">2</xref></contrib><contrib contrib-type="author"><name><surname>Ronday</surname><given-names>H Karel</given-names></name><xref ref-type="aff" rid="A3">3</xref></contrib><contrib contrib-type="author"><name><surname>Kerstens</surname><given-names>Pit J S M</given-names></name><xref ref-type="aff" rid="A4">4</xref></contrib><contrib contrib-type="author"><name><surname>Seys</surname><given-names>Patrick E H</given-names></name><xref ref-type="aff" rid="A5">5</xref></contrib><contrib contrib-type="author"><name><surname>Huizinga</surname><given-names>Tom W J</given-names></name><xref ref-type="aff" rid="A1">1</xref></contrib><contrib contrib-type="author"><name><surname>Dijkmans</surname><given-names>Ben A C</given-names></name><xref ref-type="aff" rid="A4">4</xref><xref ref-type="aff" rid="A6">6</xref></contrib><contrib contrib-type="author"><name><surname>Allaart</surname><given-names>Cornelia F</given-names></name><xref ref-type="aff" rid="A1">1</xref></contrib></contrib-group><aff id="A1"><label>1</label>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</aff><aff id="A2"><label>2</label>Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands</aff><aff id="A3"><label>3</label>Department of Rheumatology, Haga Hospital, The Hague, The Netherlands</aff><aff id="A4"><label>4</label>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</aff><aff id="A5"><label>5</label>Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands</aff><aff id="A6"><label>6</label>Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands</aff><author-notes><corresp><label>Correspondence to</label> Dr N B Klarenbeek, Department of Rheumatology, C-01-R, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands; <email xlink:type="simple">n.b.klarenbeek@lumc.nl</email></corresp></author-notes><pub-date pub-type="ppub"><month>6</month><year>2011</year></pub-date><pub-date pub-type="epub-original"><day>17</day><month>3</month><year>2011</year></pub-date><pub-date pub-type="epub"><day>17</day><month>3</month><year>2011</year></pub-date><volume>70</volume><volume-id pub-id-type="other">70</volume-id><volume-id pub-id-type="other">70</volume-id><issue>6</issue><issue-id pub-id-type="other">annrheumdis;70/6</issue-id><issue-id pub-id-type="other">6</issue-id><issue-id pub-id-type="other">70/6</issue-id><fpage>1039</fpage><history><date date-type="accepted"><day>1</day><month>2</month><year>2011</year></date></history><permissions><copyright-statement>Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions</copyright-statement><copyright-year>2011</copyright-year></permissions><self-uri content-type="pdf" xlink:role="full-text" xlink:href="annrheumdis-70-1039.pdf"></self-uri><abstract><sec><title>Objective</title><p>To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up.</p></sec><sec><title>Methods</title><p>508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS <1.6 during ≥6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages.</p></sec><sec><title>Results</title><p>After 5 years, 48% of patients were in clinical remission (DAS <1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2–5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response.</p></sec><sec><title>Conclusion</title><p>Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.</p></sec></abstract></article-meta></front></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo><title>The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study</title><partName>Extended report</partName></titleInfo><titleInfo type="alternative" contentType="CDATA"><title>The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study</title><partName>Extended report</partName></titleInfo><name type="personal"><namePart type="given">Naomi B</namePart><namePart type="family">Klarenbeek</namePart><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Melek</namePart><namePart type="family">Güler-Yüksel</namePart><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Sjoerd M</namePart><namePart type="family">van der Kooij</namePart><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">K Huub</namePart><namePart type="family">Han</namePart><affiliation>Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">H Karel</namePart><namePart type="family">Ronday</namePart><affiliation>Department of Rheumatology, Haga Hospital, The Hague, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Pit J S M</namePart><namePart type="family">Kerstens</namePart><affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Patrick E H</namePart><namePart type="family">Seys</namePart><affiliation>Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Tom W J</namePart><namePart type="family">Huizinga</namePart><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Ben A C</namePart><namePart type="family">Dijkmans</namePart><affiliation>Department of Rheumatology, Jan van Breemen Institute, Amsterdam, The Netherlands</affiliation><affiliation>Department of Rheumatology, VU Medical Center, Amsterdam, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Cornelia F</namePart><namePart type="family">Allaart</namePart><affiliation>Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><dateIssued encoding="w3cdtf">2011-06</dateIssued><dateCreated encoding="w3cdtf">2011-03-17</dateCreated><copyrightDate encoding="w3cdtf">2011</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract>Objective To compare clinical and radiological outcomes of four dynamic treatment strategies in recent-onset rheumatoid arthritis (RA) after 5 years follow-up. Methods 508 patients with recent-onset RA were randomly assigned into four treatment strategies: sequential monotherapy; step-up combination therapy; initial combination with prednisone; initial combination with infliximab. Treatment adjustments were made based on 3-monthly disease activity score (DAS) measurements (if DAS >2.4 next treatment step; if DAS ≤2.4 during ≥6 months taper to maintenance dose; if DAS <1.6 during ≥6 months stop antirheumatic treatment). Primary and secondary outcomes were functional ability, joint damage progression, health-related quality of life and (drug-free) remission percentages. Results After 5 years, 48% of patients were in clinical remission (DAS <1.6) and 14% in drug-free remission, irrespective of initial treatment. After an earlier improvement in functional ability and quality of life with initial combination therapy, from 1 year onwards clinical outcomes were comparable across the groups and stable during 5 years. The initial combination groups showed less joint damage in year 1. In years 2–5 annual progression was comparable across the groups. After 5 years, initial combination therapy resulted in significantly less joint damage progression, reflecting the earlier clinical response. Conclusion Irrespective of initial treatment, an impressive improvement in clinical and radiological outcomes of RA patients can be achieved with dynamic treatment aimed at reducing disease activity, leading to 48% remission, 14% drug-free remission and sustained functional improvement. Starting with combination therapy resulted in earlier clinical improvement and less joint damage without more toxicity.</abstract><relatedItem type="host"><titleInfo><title>Annals of the Rheumatic Diseases</title></titleInfo><titleInfo type="abbreviated"><title>Ann Rheum Dis</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">0003-4967</identifier><identifier type="eISSN">1468-2060</identifier><identifier type="PublisherID">ard</identifier><identifier type="PublisherID-hwp">annrheumdis</identifier><identifier type="PublisherID-nlm-ta">Ann Rheum Dis</identifier><part><date>2011</date><detail type="volume"><caption>vol.</caption><number>70</number></detail><detail type="issue"><caption>no.</caption><number>6</number></detail><extent unit="pages"><start>1039</start></extent></part></relatedItem><identifier type="istex">13B207CBF804CAEE46AE02E9D5AF73B776C4F230</identifier><identifier type="ark">ark:/67375/NVC-2ZWQGB8D-T</identifier><identifier type="DOI">10.1136/ard.2010.141234</identifier><identifier type="href">annrheumdis-70-1039.pdf</identifier><identifier type="ArticleID">annrheumdis141234</identifier><identifier type="PMID">21415052</identifier><identifier type="local">annrheumdis;70/6/1039</identifier><accessCondition type="use and reproduction" contentType="copyright">Published by the BMJ Publishing Group Limited. 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