Practice based evaluation of the longterm benefit of second line agents in rheumatoid arthritis

A hypothetical practice based consortium to evaluate treatment of early rheumatoid arthritis (RA) is discussed. It would consist of a coordinating center and many practicing rheumatologists. Patients with RA within 3 to 12 months of disease onset who met strict entry criteria would be offered enrollment in their choice from a menu of protocols that includes standard and aggressive treatment options and would be followed for a long time. Standard efficacy assessments would be carried out at fairly long intervals, with emphasis on erosive changes in wrist, hands and feet x-rays. Analysis would be done across drug protocols within homogeneous subgroups of patients who have been stratified by comparable entry characteristics, using those who develop erosions during treatment with nonsteroidal antiinflammatory drugs only as the standard for comparison. This approach can be used to identify risk factors that predict subsequent erosive joint damage, and to select a few promising drugs, combinations and therapeutic strategies for subsequent definitive studies.