NEW YORK (Reuters Health)—Methotrexate with step-down glucocorticoid remission induction (COBRA Slim) is an effective, safe and feasible initial treatment strategy for patients with early rheumatoid arthritis (RA), researchers from Belgium report.
Patients with early RA should be treated rapidly, intensively and to target, according to current guidelines, they note in a paper online July 18 in Annals of the Rheumatic Diseases. But questions regarding the optimal dosage and combination of drugs remain.
Dr. Diederik De Cock from KU Leuven and colleagues in the CareRA trial compared the effectiveness of different initial conventional synthetic disease-modifying antirheumatic drug (csDMARD) combinations, with or without glucocorticoid remission induction, in 289 high-risk and 90 low-risk patients with early RA.
High-risk patients were randomized to COBRA Classic (weekly methotrexate, daily sulfasalazine and a weekly step-down scheme of oral prednisone); COBRA Slim (weekly methotrexate with a weekly step-down scheme of oral prednisone); or COBRA Avant Garde (weekly methotrexate, daily leflunomide and a weekly step-down scheme of oral prednisone). Low-risk patients were randomized to COBRA Slim or methotrexate tight step-up (with no oral steroids allowed).
In the high-risk group, there were no differences in the primary outcome—remission at Week 52 as defined by DAS28(CRP) below 2.6—between the treatments.
Similarly, the low-risk group had remission rates of 67.4% with COBRA Slim and 57.4% with methotrexate tight step-up (p=0.329).
There were more treatment adaptations and glucocorticoid injections in COBRA Slim patients, and there were numerically fewer therapy-related adverse events with COBRA Slim than with the other regimens, although these differences were small and did not achieve statistical significance.
“We propose an effective, safe, feasible and standardized initial treat-to-target strategy, COBRA Slim, yielding excellent results in all patients with early RA regardless of classical prognostic markers, with high remission rates and low numbers of patients remaining on chronic glucocorticoids or biological therapy,” the researchers conclude.
The study had no commercial funding, and the researchers reported no conflicting interests.
Dr. De Cock did not respond to a request for comments.