Drug Therapy in Undifferentiated Arthritis
Drug Therapy in Undifferentiated Arthritis
Undifferentiated arthritis (UA) is defined as an inflammatory oligoarthritis or polyarthritis in which no definitive diagnosis can be made. We performed a literature review to assess the efficacy of various drug therapies in patients with UA. The literature search was conducted using electronic databases Pubmed, EMBASE and MEDLINE in adults with UA or early arthritis (not fulfilling the American College of Rheumatology (ACR) 1987 or ACR/European League Against Rheumatism (EULAR) 2010 criteria for rheumatoid arthritis). Drug therapy consisted of disease modifying antirheumatic drugs (DMARDs), biological agents and oral, intramuscular or intra-articular corticosteroids. Nine publications on eight randomised controlled trials (RCTs), two publications on two uncontrolled open-label trials and seven publications on three cohort studies were included. Temporary treatment with methotrexate (MTX), abatacept and intramuscular corticosteroids were demonstrated in RCTs with 12 months to 5 years follow-up to be more effective than placebo in suppressing disease activity or radiological progression. One study suggests that DMARD combination therapy is, at least after 4 months, superior to MTX monotherapy in patients with UA at high risk of developing persistent arthritis. The open-label uncontrolled trials and cohort studies also suggested that early treatment may provide immediate suppression of inflammation. The long-term benefit of early treatment in UA remains unclear. In conclusion, patients with UA benefit from early treatment with MTX. Combining multiple DMARDs or DMARDs with corticosteroids and biological agents may be even more beneficial. However, which treatment may provide the best results or may alter the disease course has still to be determined. More RCTs with longer follow-up time are needed.
Undifferentiated arthritis (UA) is defined as an inflammatory oligoarthritis or polyarthritis in which no definitive diagnosis can be made, and which over time may naturally evolve into a chronic inflammatory disease or into remission. Several observational cohorts of patients with early arthritis have shown that, depending on the inclusion criteria, 17–32% of the patients progress to rheumatoid arthritis (RA), while 40–55% achieve spontaneous remission.
Since many studies have proven that early treatment of RA improves clinical, functional and radiological outcomes, the question has risen if treatment in the stage of UA may be even more beneficial. The so-called 'window of opportunity theory' hypothesises that in an early stage of RA, possibly in the stage of UA, a period may exist in which the disease course can be altered by the appropriate treatment, preventing it from becoming a chronic and disabling disease. In 2010, new classification criteria have been published to enable earlier diagnosis and treatment of patients with RA. Recent data have shown that patients indeed are diagnosed earlier, but the benefit of the new criteria in terms of long-term disease outcome still needs to be elucidated. Furthermore, also with these new criteria part of the patients with inflammatory oligoarthritis or polyarthritis cannot (yet) be classified as RA.
To investigate whether early initiation of disease modifying antirheumatic drugs (DMARDs) is beneficial for patients with UA, we performed a systematic literature review to identify all articles on disease outcomes of drug treatment in patients with UA, and aimed to assess the efficacy of the different drug therapies.
Abstract and Introduction
Abstract
Undifferentiated arthritis (UA) is defined as an inflammatory oligoarthritis or polyarthritis in which no definitive diagnosis can be made. We performed a literature review to assess the efficacy of various drug therapies in patients with UA. The literature search was conducted using electronic databases Pubmed, EMBASE and MEDLINE in adults with UA or early arthritis (not fulfilling the American College of Rheumatology (ACR) 1987 or ACR/European League Against Rheumatism (EULAR) 2010 criteria for rheumatoid arthritis). Drug therapy consisted of disease modifying antirheumatic drugs (DMARDs), biological agents and oral, intramuscular or intra-articular corticosteroids. Nine publications on eight randomised controlled trials (RCTs), two publications on two uncontrolled open-label trials and seven publications on three cohort studies were included. Temporary treatment with methotrexate (MTX), abatacept and intramuscular corticosteroids were demonstrated in RCTs with 12 months to 5 years follow-up to be more effective than placebo in suppressing disease activity or radiological progression. One study suggests that DMARD combination therapy is, at least after 4 months, superior to MTX monotherapy in patients with UA at high risk of developing persistent arthritis. The open-label uncontrolled trials and cohort studies also suggested that early treatment may provide immediate suppression of inflammation. The long-term benefit of early treatment in UA remains unclear. In conclusion, patients with UA benefit from early treatment with MTX. Combining multiple DMARDs or DMARDs with corticosteroids and biological agents may be even more beneficial. However, which treatment may provide the best results or may alter the disease course has still to be determined. More RCTs with longer follow-up time are needed.
Introduction
Undifferentiated arthritis (UA) is defined as an inflammatory oligoarthritis or polyarthritis in which no definitive diagnosis can be made, and which over time may naturally evolve into a chronic inflammatory disease or into remission. Several observational cohorts of patients with early arthritis have shown that, depending on the inclusion criteria, 17–32% of the patients progress to rheumatoid arthritis (RA), while 40–55% achieve spontaneous remission.
Since many studies have proven that early treatment of RA improves clinical, functional and radiological outcomes, the question has risen if treatment in the stage of UA may be even more beneficial. The so-called 'window of opportunity theory' hypothesises that in an early stage of RA, possibly in the stage of UA, a period may exist in which the disease course can be altered by the appropriate treatment, preventing it from becoming a chronic and disabling disease. In 2010, new classification criteria have been published to enable earlier diagnosis and treatment of patients with RA. Recent data have shown that patients indeed are diagnosed earlier, but the benefit of the new criteria in terms of long-term disease outcome still needs to be elucidated. Furthermore, also with these new criteria part of the patients with inflammatory oligoarthritis or polyarthritis cannot (yet) be classified as RA.
To investigate whether early initiation of disease modifying antirheumatic drugs (DMARDs) is beneficial for patients with UA, we performed a systematic literature review to identify all articles on disease outcomes of drug treatment in patients with UA, and aimed to assess the efficacy of the different drug therapies.
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