Combining drugs at the start of rheumatoid arthritis may help most

THE QUESTION As treatment of rheumatoid arthritis has expanded from simply relieving the chronic pain of inflamed joints to also preventing the destruction of bone and cartilage, an array of drugs has become available, for use alone or in combination. What strategy works best?

THIS STUDY randomly assigned 508 adults, mostly women, recently diagnosed with rheumatoid arthritis to one of four types of medication programs: (1) methotrexate alone, switching to a different disease-modifying, anti-rheumatic drug (DMARD) if needed; (2) a step-up program that starts with methotrexate but adds other DMARDs and the steroid prednisone; (3) an initial combination of methotrexate, sulphasalazine (an anti-inflammatory) and prednisone; or (4) a combination of methotrexate and infliximab, a drug that blocks a substance (tumor necrosis factor) that causes inflammation. After a year, the ability to function had improved in all groups, with the disease in remission in 32 percent of the participants.

But more people from groups 3 and 4 — those whose had taken a combination of drugs from the start — improved, and they improved more quickly, than the others. Compared with hand and foot X-rays taken at the start of the study, groups 3 and 4 also showed less progression of joint damage, with no progression shown for 87 percent and 93 percent of the groups, respectively, compared with 67 percent for group 1 and 73 percent for group 2.

WHO MAY BE AFFECTED BY THESE FINDINGS? People with rheumatoid arthritis, which most often begins between ages 30 and 50. Women are nearly three times more likely to get the disease, but it tends to affect men more severely.

CAVEATS About 41 percent of the participants, roughly divided equally among the groups, reported side effects, mainly gastrointestinal and skin problems. The study was funded in part by Centocor and Schering-Plough, which had paid fees to one author.