BeST Trial and 10-Year Outcomes of Four Treatment Strategies Save

Markusse and investigators from The Netherlands have reported their 10 year results of treating early rheumatoid arthritis (RA) patients using targeted treatment strategies.

The BeST study compared the outcomes of ERA patients treated with 1) Sequential monotherapy (strategy 1), 2) step-up combination therapy (strategy 2), 3) initial combination therapy with prednisone (strategy 3) or 4) with infliximab (strategy 4), all followed by targeted treatment aiming at low disease activity.  The reported outcomes of this prospective cohort study included remission, drug use and survival.

Of the 508 patients enrolled, 38% dropped out of the study overall. This was least (28%) in strategy 4 and higher with the other strategies (40-45% for strategies 1 to 3).

At year 10, remission was achieved by 53% and 14% of patients were in drug-free remission, off of all DMARDs or biologics. The standardized mortality ratio was 1.16 (95% CI, 0.92 to 1.46) and did not differ between the 4 strategies (P = 0.81).

The BeST trial was novel in many ways.  It showed that in early RA, initial aggressive combination therapy (groups 3 and 4) yielded faster clinical improvement. Despite proving the short-term (1yr.) benefits of aggressive combination therapy, the BeST trial also showed the long term advantages to using a treat-to-target style of management, wherein treatment change was guided by validated clinical measures and ultimately maximized each group's response to the point there were no long-term differences after the 2nd year.  

BeST also documented the importance of disease flares in RA outcomes. Flares were associated with increases in disease activity, functional deterioration and radiographic progression. 

BeST also demonstrated that with early RA interventions, realistic goals and outcomes may include drug-free remission, prevention of radiographic damage, functional deterioration and normalized survival.