In arthritis treatment, sometimes more isn’t better

Each week, we select an article from an influential journal that has broad implications for healthcare and has just become available for free online.

This study is an example of how useful so-called negative results can be. The authors recruited patients who were recently diagnosed with “mild” arthritis, and the goal was to compare standard (conservative) treatment with aggressive treatment using more advanced drugs. The advanced drugs, needless to say, are more expensive and have the potential to cause more severe side effects. Nonetheless, isn’t it better to give it all you’ve got?

Not always, as it turned out. Over a two-year period, the authors saw no meaningful difference in disease progression between patients who received standard treatment and those who received more aggressive treatment. And the patients who received the more aggressive treatments also experienced more side effects.

The lesson, which potentially applies to a lot of diseases other than arthritis, is that the latest, most powerful treatment isn’t always better. Both clinicians and patients will do well to keep this in mind.

Check out the abstract below or go right to the free full text.

PubMed Citation:

Rheumatology (Oxford). 2012 Apr;51(4):686-94. Epub 2011 Dec 13.

Aggressive therapy in patients with early arthritis results in similar outcome compared with conventional care: the STREAM randomized trial.

van Eijk IC, Nielen MM, van der Horst-Bruinsma I, Tijhuis GJ, Boers M, Dijkmans BA, van Schaardenburg D.


Jan van Breemen Research Institute/Reade, Dr Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands.


Objective. To compare the effects of aggressive tight control therapy and conventional care on radiographic progression and disease activity in patients with early mild inflammatory arthritis. Methods. Patients with two to five swollen joints, Sharp-van der Heijde radiographic score (SHS) <5 and symptom duration ≤2 years were randomized between two strategies. Patients with a definite non-RA diagnosis were excluded. The protocol of the aggressive group aimed for remission (DAS < 1.6), with consecutive treatment steps: MTX, addition of adalimumab and combination therapy. The conventional care group followed a strategy with traditional DMARDs (no prednisone or biologics) without DAS-based guideline. Outcome measures after 2 years were SHS (primary), remission rate and HAQ score (secondary). Results. Eighty-two patients participated (60% ACPA positive). In the aggressive group (n = 42), 19 patients were treated with adalimumab. In the conventional care group (n = 40), 24 patients started with hydroxychloroquin (HCQ), 2 with sulfasalazine (SSZ) and 14 with MTX. After 2 years, the median SHS increase was 0 [interquartile range (IQR) 0-1.1] and 0.5 (IQR 0-2.5), remission rates were 66 and 49% and HAQ decreased with a mean of -0.09 (0.50) and -0.25 (0.59) in the aggressive and conventional care group, respectively. All comparisons were non-significant. Conclusion. In patients with early arthritis of two to five joints, both aggressive tight-control therapy including adalimumab and conventional therapy resulted in remission rates around 50%, low radiographic damage and excellent functional status after 2 years. However, full disease control including radiographic arrest in all patients remains an elusive target even in moderately active early arthritis. Trial registration. Dutch Trial Register,, NTR 144.

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