UTRECHT, The Netherlands—Intensive methotrexate (MTX) therapy adjusted with the help of a quantitative computerized decision program may move more early rheumatoid arthritis (RA) patients into remission than conventional MTX treatment, according to newly published results from the Computer Assisted Management in Early Rheumatoid Arthritis (CAMERA) trial. The findings are published online in the Annals of Rheumatic Diseases.¹

"The key message of this paper is that when patients with early RA are treated according to an intensive treatment strategy, remission is achieved more often, faster, and for a longer period of time than with a conventional strategy approach," conclude researchers led by S.M.M. Verstappen, MD, of the University Medical Center in Utrecht, The Netherlands.

In the 2-year trial, 299 patients with early RA were randomly assigned to an intensive strategy group or a conventional strategy group. Patients in both groups received MTX with the goal of remission. Patients in the intensive treatment group came to the outpatient clinic once every month, while those in the conventional group were seen once every 3 months.

In the intensive therapy group, doctors adjusted the MTX dosage to the individual patient on the basis of predefined response criteria using a computerized decision program. Data on swollen joint  and tender joint counts, erythrocyte sedimentation rate, and the visual analogue scale for general well-being were entered into the computer at each visit. The program then calculated whether criteria for response to treatment had been met, and MTX dose was adjusted accordingly.

By contrast, study participants in the conventional group had their MTX doses adjusted based solely on the opinion of their doctor. Cylosporine was added if patients had an inadequate response to the maximal tolerated MTX dose of 30 mg/week.

Half of the intensive strategy patients achieved at least one period of remission during the 2-year trial compared with 37% of patients in the conventional strategy group. Moreover, area under the curve (AUC) for nearly all clinical variables were significantly lower for the intensive treatment group compared with the conventional treatment group.

"The results of this study show that it is possible to substantially enhance the clinical efficacy early in the course of the disease by intensifying treatment with MTX, aiming for remission, tailored to the individual patient," the researchers conclude. "Furthermore, participating rheumatologists indicated that the computerized decision program could be a helpful tool in their daily clinical practice."

Quantitative approach moves more RA patients to remission

David S. Pisetsky, MD, PhD, chief of the division of rheumatology at Duke University Medical Center in Durham, North Carolina, told CIAOMed that this is "an interesting study and what is shows you is that if you really follow disease activity and treat based on it, the outcome will be better."

Dr. Pisetsky said that quantitative approaches may be better than physician and patient global assessments. "That's the trend that emerging from a lot of studies," he said. "Try to treat by the numbers and you will do better."

"The CAMERA study is an interesting study and showed that the standard methotrexate dose escalation does not control disease sufficiently," Ernest H. Choy, MD, with the department of rheumatology, at King's College London, in the UK, told CIAOMed. "We do not do the CAMERA regimen, but the COBRA regimen and combine steroids with methotrexate which has the same benefit with rapid disease control." The COBRA regimen consists of MTX plus an initial dose of prednisolone 60 mg/day, tapered to 7.5 mg/day at week 28, and then stopped at week 35.

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