Combination drug therapy retards the development of rheumatoid atlantoaxial subluxations

Abstract

Objective. To compare the efficacy of combination therapy with disease-modifying antirheumatic drugs (DMARDs) versus single therapy with DMARDs in the prevention of early cervical spine changes in patients with rheumatoid arthritis (RA).Methods. One hundred ninety-five patients with recent-onset RA (mean disease duration 8 months) were randomly assigned to receive a combination of DMARDs (sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone) or a single DMARD with or without prednisolone. After 2 years of followup, cervical spine radiographs were taken of 176 of these patients (85 in the combination-therapy group and 91 in the single-therapy group). These radiographs were evaluated, and the findings were correlated with the therapy strategies as well as with peripheral joint destruction and clinical and laboratory variables describing the disease activity.Results. Anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI; i.e., vertical subluxation), and subaxial subluxation (SAS) were found in only 6 (3.4%), 2 (1.1%), and 5 (2.8%) of the patients, respectively. Interestingly, none of the patients in the combination-therapy group had aAAS or AAI. The incidences of aAAS and AAI in the single-therapy group were 6.6% and 2.2%, respectively. SAS was present in 2 patients (2.2%) in the single-therapy group and in 3 patients (3.5%) in the combination-therapy group. The difference in the incidence of aAAS between the treatment groups was statistically significant (P ‫؍‬ 0.029). None of the patients with cervical spine changes achieved remission of RA during the study.Conclusion. In the present study, the incidence of cervical spine subluxations in patients treated with single-drug therapy was in accord with findings of previous studies. However, none of the patients in the combination-therapy group had aAAS or AAI. These findings suggest that early, aggressive combination-DMARD therapy with sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone can prevent or retard the development of rheumatoid atlantoaxial disorders.

Trends in Nonoperative Treatment Modalities Prior to Cervical Surgery and Impact on Patient-Derived Outcomes: Two-Year Analysis of 1522 Patients From the Prospective Spine Treatment Outcome Study

“…1 Nonoperative treatment has been shown to provide some benefits to these patients, but studies have been limited by small sample sizes, minimal follow-up data, and lack of control groups. [2][3][4][5][6][7] Additionally, these studies examined the immediate and short-term effects of these interventions without long-term outcome data for patients who eventually undergo surgery. For example, Manchikanti et al 8 performed a randomized study in which patients with chronic axial neck and radicular pain, attributed to cervical disc herniations, received cervical epidural injections with local anesthetic with or without corticosteroids.…”

Early and extensive erosiveness in peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis

“…We reported earlier that combination therapy with traditional DMARDs retarded the early development of atlantoaxial subluxations over 2 years (5). In the present study, we found a low long-term prevalence of cervical spine subluxations in patients who were treated early and continuously with traditional DMARDs.…”

“…We have previously reported that up to 42% of patients treated with conventional therapy exhibit aAAS, AAI, or SAS after 20 years of RA (4). We also recently showed that aggressive treatment of RA with a combination of disease-modifying antirheumatic drugs (DMARDs) retards or prevents early development of atlantoaxial subluxations (5). However, very little is known of the long-term prevalence of RArelated cervical spine changes in patients who are treated actively with DMARDs from the time of diagnosis.…”

Columna cervical reumática

“…Frente a la presencia de compromiso radiológico progresivo, o deterioro neurológico, se debe considerar el tratamiento quirúrgico2,11. Adicionalmente, existen estudios que sugieren que, el tratamiento precoz con drogas antirreumáticas modificadoras de la enfermedad es capaz de prevenir o retardar el desarrollo de alteraciones a nivel atlanto-axial 18,19 . Las indicaciones quirúrgicas incluyen: presencia de inestabilidad, déficit neurológico y dolor cervical intratable 2,11 Frente a la presencia de déficit neurológico o de dolor intratable, la indicación quirúrgica es clara.…”

“…relación a la recuperación neurológica. Uno de los predictores Frente a la presencia de compromiso radiológico progresivo, de recuperación post operatoria más importante es la condicio deterioro neurológico, se debe considerar el tratamiento ren que, el tratamiento precoz con drogas antirreumáticas modificadoras de la enfermedad es capaz de prevenir o retardar el desarrollo de alteraciones a nivel atlanto-axial 18,19 .…”