Should rheumatoid arthritis be treated conservatively or aggressively

The therapeutic armamentarium of the rheumatologist has improved greatly with the introduction of diseasemodifying anti-rheumatic drugs (DMARDs) and biological response modifiers (BRMs) for rheumatoid arthritis (RA). These agents have been shown to be effective in controlling disease progression, unlike nonsteroidal anti-inflammatory drugs (NSAIDs), which are used to provide symptomatic relief [1]. In addition, solid clinical research has provided evidence that treatment with combinations of these drugs affords further improvements in efficacy without unacceptable compromises in toxicity [2, 3]. The majority of rheumatologists have experience with the new treatment modalities and are well informed about their relative therapeutic efficacies and toxicities. However, a clear consensus has not yet been reached on either the order in which specific DMARDs should be used in RA or the criteria used to judge the efficacy of a treatment. These are influenced by a number of factors, including: the accuracy of diagnosis in the earliest phase of the disease; the accuracy of disease progression monitoring and the ability to predict outcome with respect to joint destruction and loss of function; the balance of potential adverse effects of treatment with the potential advantages of ameliorating disease progression; and consideration of direct and indirect costs. To highlight the differences in opinion between rheumatologists with respect to the application of a diagnostic and therapeutic algorithm for RA, and to distil the clearest view of the value of early intervention and tailored therapies, four rheumatologists entered a debate at the Amgen RA European Summit Conference (14–15 March 2002, Montreux, Switzerland) on conservative vs aggressive treatment. After the presentation of a case study of a woman with severe RA (see Case study), Professors David Scott (UK) and Maarten Boers (The Netherlands) argued the most appropriate choice of RA therapy. Following on, Professors Theodore Pincus (USA) and Stefano Bombardieri (Italy) debated an aggressive vs conservative approach, respectively, to the monitoring of disease progression and therapeutic choices during the course of disease. The need for such a debate was clearly illustrated by the response of the delegates to questions posed at the beginning of the session. For example, when asked what the initial therapeutic approach would be, support ranged widely across the spectrum of conservative (monotherapy with DMARDs other than hydroxychloroquine) to aggressive therapy (combination DMARD therapy or BRMs). Furthermore, the therapeutic goal of the voting rheumatologists with respect to an acceptable level of residual disease activity was heterogeneous.