Intensive management of early rheumatoid arthritis: the TICORA and TEAR studies

Observations form other biological models, principally Type 1 DM, led to the formation of a hypothesis that tight control of synovial inflammation using an intensive management strategy would lead to improved outcomes for patients with early RA. The TICORA study tested this hypothesis by randomising patient to routine or intensive management. It demonstrated that frequent review, formal assessment of disease activity and escalation of therapy in patients with persistent disease activity led to substantial increases in the rate of remission, reduced physical disability and radiographic progression. Its follow up study, TEAR, tested whether these results could be improved further by employing triple therapy from the outset, but the results suggested that a step-up strategy (moving to triple therapy only in those patients who have persistent disease activity on monotherapy) was as effective as parallel triple therapy. The studies have contributed to a consensus that early RA must be treated early and intensively, with the aim of achieving low disease activity or remission in all patients. The challenge to the clinical community is to ensure that this strategy is implemented in every rheumatologist's practice.