In a recent article, Axel Finckh and colleagues assessed the potential cost-effectiveness of the major therapeutic strategies for very early (that is, symptom duration of less than 1 month) rheumatoid arthritis (Finckh, A. et al. Ann. Intern. Med. 151, 612-621; 2009). For each of the different therapeutic strategies, the investigators compared radiographic evidence of joint damage with functional disability at various time points-toxicity, treatment initiation or discontinuation, or death. Estimates of lifetime costs and benefits were expressed as quality-adjusted life years (QALYs) and a decision analytic model with probabilistic sensitivity analyses applied. The primary comparison was between the pyramid strategy-initial treatment with NSAIDs, patient education, exercise, pain management, low-dose glucocorticoids as needed and disease-modifying anti-rheumatic drugs (DMARDs; leflunomide, sulfasalazine, hydroxychloroquine or methotrexate) for nonresponders at 1 year-and two early, aggressive treatment strategies, which consisted of either methotrexate within 12 weeks of symptom onset (early DMARD strategy) or methotrexate plus a biologic agent (early biologic strategy).
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