Maxime Verhoeven

222 Chapter 13 SUMMARY The last decades, rheumatoid arthritis (RA) patients are treated according to the tight-control and treat-to-target principles with the target of remission or low disease activity (LDA). 1,2 Regarding disease modifying anti-rheumatic drug (DMARD) therapy, initial therapy with a single conventional synthetic (cs)DMARD, preferably methotrexate (MTX), with or without short-term glucocorticoids (GCs; ‘bridging therapy’) is advised. Biological (b)DMARDs, regarded as more effective DMARDs and often combined with a csDMARD, are not advised as initial therapy. This seems counterintuitive given that a potentially larger impact might be expected on patients outcome when a more intensive treatment is given earlier in the disease within the ‘window of opportunity’ period. 1,3 The benefits of intensive treatment strategies (with bDMARDs) should be carefully weighed against adverse effects, costs related to the disease including its treatment, and the risk of potential overtreatment. Aspects of treatment strategies with the aim to further improve efficiency and effectiveness of care for RA patients are subjects of study in this thesis. The first part evaluates DMARD therapy approaches in treat-to- target treatment strategies in (early) RA, including effectiveness, cost-effectiveness and longer-term outcomes. The second part of this thesis explores whether monitoring of disease activity can be performed accurately using objective reading of inflammation with the HandScan, sparing deployment time of a healthcare professional, with the ultimate aim of better implementation of the treat-to-target principle in daily care. Summary of PART I of the thesis Several clinical trials have studied more intensive initial DMARD strategies with the initial aim of rapidly inducing clinical remission, compared to starting a csDMARD, with/ without GC ‘bridging’, the latter strategy according to current recommendations in early RA. We performed a systematic literature review on this subject, see chapter 2 . From our results it could be concluded that more intensive strategies, specifically those initiating a bDMARD, are more effective in achieving remission when compared to strategies initiating single csDMARD therapy. However, when compared to csDMARD strategies including GC bridging, the more intensive strategies with bDMARD were no longer more effective. These results confirmed that GCs are a highly effective therapy in (early) RA (and can be regarded as DMARD). In chapter 3 , we aimed to compare a treatment strategy initiating GC in low-median dose as DMARD (i.e., not short-term as bridging therapy) concomitantly to MTX, versus 2 strategies initiating a bDMARD (i.e., TCZ in both strategies) in early DMARD-naïve patients. We found that TCZ-based strategies compared to MTX with prednisone resulted in lower disease activity using disease activity score assessing 28 joints (DAS28-)based outcomes, whereas using a modification