With the recent advances in DMARD therapy and studies indicating that early and aggressive treatment for rheumatoid arthritis (RA) may improve the long-term functional outcome for patients, one might wonder whether rheumatologists have altered their choice of first-line therapy for early RA. In an attempt to answer this question, Erkan et al mailed out a questionnaire to 995 rheumatologists in the United States. The questionnaire provided 3 patient scenarios of early RA, either presenting with signs/symptoms of mild, moderate, or severe disease activity and asked physicians to identify what first-line therapy they would choose with and without cost taken into consideration. Choices included NSAID/COX2/corticosteroids (CS), and mono, double, or triple DMARD therapy. The response rate was 37.7% (n=375) and did not vary by geographical location. Treatment with a single DMARD was chosen by 75% of physicians for mild RA, by 60% of physicians for moderate RA, and by 41% of physicians for severe RA, regardless of cost. Differences in a physician's choice of first-line therapy of double and triple DMARDs were noted for "cost not considered" vs "cost considered" only in early RA patients presenting with severe disease, 45% vs 29% (p=0.00001) and 12% vs 23% (p=0.00002), respectively. In patients presenting with mild disease, 10% of physicians chose NSAID/COX2/CS as first-line therapy.

If these data reflect the trends of rheumatologists as a whole, aggressive DMARD therapy is not broadly used for first-line therapy in patients presenting with signs and symptoms of early RA.

Editorial Comments: The obvious criticism is the low response rate begging the question of whether the respondents reflect the current standard of care. Nonetheless, this is interesting information confirming other studies showing that physicians in practice may not be implementing multiple DMARD therapy in early RA independent of cost considerations.

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