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Do we need to apply a T2T strategy even in ACPA-negative early rheumatoid arthritis? YES
  1. Gianfranco Ferraccioli,
  2. Barbara Tolusso,
  3. Anna Laura Fedele and
  4. Elisa Gremese
  1. Division of Rheumatology-Fondazione Gemelli, Institute of Rheumatology and Affine Sciences, School of Medicine, Catholic University of the Sacred Heart, Rome, Italy
  1. Correspondence to Professor Gianfranco Ferraccioli; gf.ferraccioli{at}

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Over the past 10 years, the clinical and therapeutic approach to rheumatoid arthritis (RA) has tremendously improved the outcomes of patients, thanks to the recommendations on how to deal with early RA,1 on how to treat and monitor patients,2 and on how to assess predictors of response or of progression and non-response to initial therapy with conventional synthetic disease modifying antirheumatic drugs (csDMARDs).3 These predictors have been well defined over the years and include: (A) high-disease activity; (B) autoantibody positivity (rheumatoid factor and/or antibodies to citrullinated proteins) and (C) the early presence of joint damage.3

The logical consequence of the eighth recommendation on the management of RA2 would be to deal carefully with patients whether presenting with or without the risk factors B and C. Yet no data are available on treating patients with RA presenting with or without risk factors B and C differently. None of the trials in recent years have initially separated patients with RA with and without risk factors B and C to see whether these patients, respectively, behave differently in terms of major outcomes (remission, joint damage and disability).

Surrogate information can be obtained from randomised controlled clinical trials (RCTs) in which patients with and without all risk factors were enrolled. Looking at the long-term extension, these trials could reveal whether the risk factors really determine different outcomes in terms of gain of function and protection from joint damage, and therefore whether different approaches should be established at diagnosis.

One of the trials that gives important clues on how to properly treat patients with early RA has been the BeST trial.4 This trial has reached the 10th year of follow-up and can therefore amply provide key information on the medium to long-term course of early RA.

The rule adopted over …

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