The drug protocol in the study called for conventional DMARDs as initial treatment, starting with a weekly 15-milligram dose of methotrexate (MTX), raised to 25 milligrams in poor responders. Sulfasalazine was added after 12 weeks, if necessary. For those still not responding at six months, an anti-TNF agent, such as adalimumab (Humira), replaced the sulfasalazine.

But, Vermeer says, the majority of patients needed only the conventional drugs.

“According to the treatment protocol, anti-TNF drugs were prescribed only for a minority of patients whose disease activity remained moderate to high after insufficient effect of conventional DMARDs,” Vermeer says. “Our study shows that MTX monotherapy, followed by combined treatment with other DMARDs, when indicated, is highly successful in achieving the treatment goal of remission.”

That does not surprise Vivian P. Bykerk, MD, a rheumatologist with the Inflammatory Arthritis Center at the Hospital for Special Surgery in New York. “We’ve always known that if you get people on the right dose of methotrexate, with or without other DMARDs – and very quickly – 60 to 70 percent will respond very well and 30 percent will need a biologic.”

But Dr. Bykerk, who is also an associate professor of medicine at Weill Cornell Medical College, says the study does provide more evidence that treat-to-target can be a very important paradigm for managing RA patients . The key thing, she says, is getting early treatment. In the Dutch study, the mean duration of symptoms was 14 weeks. In other words, doctors caught the disease at an ideal time.

“What we don’t see very often is people coming in with 14 weeks of symptom development,” says Dr. Bykerk. “Usually, it’s more like four to six months.” The time lag between onset and diagnosis may be due, in part, to a lack of recognition of the disease symptoms – both on the part of the patient and some primary care doctors. “Rheumatoid arthritis is typically a disease of the smaller joints,” says Dr. Bykerk. “Not so much the bigger joints.”  She points specifically to pain and swelling in the wrist, knuckles and some joints in the feet. “There is almost no other disease that causes these symptoms,” she says.

“Our results underscore the importance of immediate treatment after diagnosis, tight control of disease activity and aiming at remission in daily clinical practice,” says Vermeer. “When remission is accepted as the therapeutic goal of RA, it is evident that disease management should include monitoring of disease activity and adjustment of therapy accordingly. We suggest a change in the current clinical approach to treating very early RA and believe that rheumatologists should make remission the mission for all patients.”