Rheumatoid Arthritis: Aiming for Cure - Commitment to Care

Abstract

This thesis is based on analyses using data from the Early Utrecht Rheumatoid Arthritis Cohort study group (EURAC; in Dutch called SRU, “Stichting Reumaonderzoek Utrecht”), mainly focusing on the latest study: Computer Assisted Management in early RA trial-II (CAMERA-II). We chose to organize this thesis into two sections: 1. Aiming for Cure: Chapters describing research regarding treatment strategies and analysis of reporting of effects. 2. Commitment to Care: Chapters describing research regarding the more subjective, patient-bound outcomes, such as psychological distress, quality of life and patients' reported disease outcomes. In the first part firstly the literature was extensively explored in two reviews. The first review on tight control strategies showed that although remission rates differed in these studies, in general were not higher in studies applying a biological DMARD from start compared to studies with initial conventional DMARD. The second review, addressing how to best treat established RA based on literature, we concluded that MTX is the anchor DMARD and should be the DMARD of choice to build a combination therapy around and combination therapy should be the treatment of choice. The next two chapters were based on research performed on the CAMERA-II data, showing in one that taking duration of remission periods into account discriminates better between treatment arms and in the other that a multibiomarker disease activity measure correlates with the disease activity score based on 28 joints. Also, in the separate biomarker outcomes, patterns could be seen making it possible to distinguish between the two treatment arms on biomarker level. In the second part of the thesis, which also contained four chapters, we were able to establish that the improvement of the treatment of rheumatoid arthritis in the past decades has resulted in an improvement of psychological and physical functioning and that the present treatment paradigm of intensive tight-control with treat-to-target (even when it is including prednisone) has no negative effect on the patients quality of life. Furthermore, the weight gain that was more prevalent in the most intensive treatment arm of CAMERA-II (MTX-based strategy with prednisone 10 mg/d vs. MTX-based strategy with placebo) was attributable to the lowering of disease activity and not a side effect of the prednisone use. Finally, we studied our hypothesis that the lack of response to biological DMARDs can be attributable to high scores on the subjective components of the DAS28. Our hypothesis did not hold: a greater reduction of the combined subjective components was seen in the good responders.