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| |  'Step-Down' Treatment For Rheumatoid Arthritis Suggested LONDON -- August 1, 1997 – Researchers in the Netherlands and Belgium report in The Lancet this week a new approach to the treatment of rheumatoid arthritis. Traditionally, treatment of this progressive disease starts with mild drugs, and steps up to progressively stronger drugs if the patient does not obtain relief of symptoms. However, rheumatoid arthritis causes irreversible damage from its onset, so more aggressive treatment early in the disease might be more effective. Dr. Maarten Boers’ and his colleagues’ approach was to hit the disease hard with strong drugs -- steroids and methotrexate -- as well as the milder sulphasalazine, at the beginning; they then phased out the strong drugs and treated the patients with sulphasalazine alone (hence, the step-down approach). The symptoms of the painful and disabling joint disease were suppressed by the combined treatment in 76 (72 percent) of the patients who received it, compared with 79 (49 percent) of another group of patients who received sulphasalazine alone throughout the trial. "Further analysis suggests that the combined therapy immediately suppressed damage progression, whereas sulphasalazine did so less effectively and with a lag of 6 to 12 months," the investigators write. The crucial question, whether the benefit of the combined treatment can be sustained, however, has a clear answer -- it cannot. By the end of the study (80 weeks) the combined treatment recipients had reverted to the same degree of disease activity as the sulphasalazine group. Dr. Paul Emery, of the University of Leeds, in the U.K., lists the main conclusions of the study in his Commentary: when inflammation is suppressed (by the strong drugs) patients gain benefit; more therapy is not necessarily more toxic; and the treatment does not change the underlying disease process, since the benefit is not maintained when the patients are on less intensive treatment. He suggests that eradication of the disease may depend on eradication of the diseased cells in the joints. Direct approaches to treatment in the joint spaces themselves may pay off. In a Research Letter in the same issue of The Lancet, Dr. DJL Joske reports on a man, aged 46, who can walk again after being crippled with rheumatoid arthritis. The man underwent bone-marrow transplantation after all conventional treatments failed to improve his symptoms. Bone-marrow transplantation carries many risks, including a 2-4 percent risk of death, and is not usually done to induce remission in severe rheumatoid arthritis. The patient had extensive counselling and was interviewed by members of the hospital ethics committee before giving his written consent. This patient had had the disease for seven years, and had spent 11 of the 12 months before his operation in hospital. He could get about only in an electric wheelchair, had become unemployed, was divorced, and had lost custody of his children. He was also depressed. The proposed bone-marrow transplantation offered him his last hope of regaining a normal life. He can now walk up to 2 km with ease. Dr Joske believes that in patients with severe disease who do not respond to other treatments, bone-marrow transplantation "is a rational and effective therapeutic option for rheumatoid arthritis refractory to conventional disease-modifying therapies".
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