Should we use poor prognosis factors to start early treatment in patients with rheumatoid arthritis?

Treatment of rheumatoid arthritis (RA) has undergone a radical change in recent years by optimization not only of classical treatments with disease modifying drugs and the introduction of new biological therapies,1–8 but also of the objectives (treat to target) in the shortand long-terms in monitoring and standardization of patients and procedures.9 It is increasingly evident that there is a window of opportunity period in which, after the diagnosis, the use of more effective therapies and established pretreatment objectives lead to improved long-term prognosis.9,10 In this sense, the proposed new referral and classification11 criteria for RA12 allow this therapeutic approach to be started early. Studies show that in the first two years of treatment any well-considered strategy may induce remission.13,14 What is more controversial is whether long-term strategies based on non-biological agents compared to early introduction of biological drugs, maintain a prolonged remission avoiding further progression of radiologic damage15,16 or disability.17 In this regard, results from trials using biological anti-TNF-alpha drugs in patients with RA cohorts of established RA patients show that active treatment and early introduction of biologic therapies are critical to the achievement of long term therapeutic objectives.18–21 The reality in our clinical practice is that despite the biological treatment, a proportion of patients with inflammatory activity persist or present radiological progression.22 The question remains whether therapy may be optimized in these patients. Recent publications such as Aletaha et al.23 warn about the importance of the persistence of swollen joints, rather than high values of C-reactive protein (CRP) as a determinant of long-term radiographic progression. It has shownadirect relationship between increases inDAS28,