Improved radiological outcome of rheumatoid arthritis: the importance of early treatment with methotrexate in the era of biological drugs.

The objective of this study is to compare the radiological progression in patients with rheumatoid arthritis (RA) diagnosed in the 1980s with those of the late 1990s until 2005 and to evaluate prognostic factors. Ninety-two RA patients who were firstly seen in our clinic from 1997 to 2005 were identified. As a control group, 89 RA patients from 1986 to 1990 were matched for the criteria disease duration (mean, 22 ± 17 months), age, and number of x-ray controls. Radiological damage was measured by the Ratingen score (RS). The baseline RS of the 1997-2005 group was significantly lower (mean, 3.8 ± 8.7 vs 7.7 ± 13.0; p < 0.0001) and showed less radiological progression during follow-up than the 1986-1990 group (ΔRS/year of 0.95 ± 2.19 vs. 5.69 ± 8.43; p < 0.0001). In the later group, more patients (73 vs. 28%) had methotrexate (MTX). Twenty-one (23%) of the patients in the later group received biological drugs. However, the subgroup 1997-2000 (n = 29), before the approval of TNF-inhibitors, had already lower baseline RS in comparison to 1986-1990 (2.7 ± 4.9; p < 0.001). Multivariate analysis showed that early start of MTX (before or directly after first consultation) was a predictor of favorable outcome (p < 0.005), as were low erythrocyte sedimentation rate at baseline and belonging to the later group. In contrast, neither treatment with glucocorticoids or biological drugs nor the overall rate of MTX or other disease-modifying antirheumatic drug use was predictive. Radiological damage is markedly diminished in RA patients seen since mid of the 1990s. Early treatment with MTX seems to be the key factor for this improved prognosis.