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Nordic research included in European guidelines for the treatment of rheumatoid arthritis

“It feels as if someone is constantly tapping my hands with a hammer.” This is how patients with rheumatoid arthritis often describe their pain. Up to two percent of the population is affected by rheumatoid arthritis, which is a condition that can attack any joint in the body. Rheumatoid arthritis often causes severe pain in patients because it eats into the cartilage and bone tissue of the joints.

What’s the best treatment for rheumatoid arthritis at the onset of the condition?

The NordStar research project has found an answer to this. The project includes researchers from Iceland, Finland, Norway, Sweden, Denmark, and the Netherlands, and is led by Merete Lund Hetland, clinical professor at the University of Copenhagen and consultant at Rigshospitalet in Glostrup.

“In the worst-case scenario, untreated rheumatoid arthritis can result in patients ending up in a wheelchair and dying prematurely, which is why it’s important to start treatment quickly. Fortunately, there are good treatments available, but while some are very cheap, others are extremely expensive. The expensive ones are biological drugs, which have been putting pressure on the health services in the Nordic countries. For the first time ever, in this research project we’ve examined three biological drugs and one conventional medicine in the same trial to find out whether we should start treatment with the cheap conventional medicines or go in with the big guns from the outset,” she says.

Merete Lund Hetland, clinical professor at the University of Copenhagen and consultant at Rigshospitalet in Glostrup. Photo: Thomas Rungstrøm.

The results were impressive

The researchers investigated two scenarios. The first one is where the condition goes into remission and the patient no longer has symptoms. This is called the clinical effect of the treatment. In the second, they examined what happened to the bones by taking X-rays of the patients to see if there was any damage to joints.

The first main finding showed that after one year, on average, the condition had subsided in 40 percent of the patients in the trial. The form of treatment that performed best is the preparation Orencia, which is one of the biological drugs. In the group of patients who were given Orencia, 60 percent experienced that the condition went into remission. For patients who received another biological drug, Cimzia, around 50 percent experienced the condition going into remission. The two drugs are statistically significantly better than the conventional treatment, which made the condition go into remission in 40 percent of participants. The third biological drug, RoActemRA, wasn’t significantly different from the conventional treatment.

“The results showed impressive percentages. What we’re saying is that when the disease is in remission, patients have neither pain nor other rheumatic symptoms, and that their blood tests are normal. That’s impressive. As for the X-rays, in all four treatments, we can see that there’s almost no destruction of the joints. So we can conclude that the winners are the two biological drugs Orencia and Cimzia, which perform best in the first round and cause the disease to go into remission. When it comes to joint damage, all four drugs are winners,” says Merete.

Patients from all over the Nordics participated

Patients with newly developed and untreated rheumatoid arthritis were recruited from the five Nordic countries and the Netherlands. A total of 812 patients participated in the comprehensive trial, making it the world’s largest investigator-initiated trial in the field of rheumatoid arthritis.

“We’re proud that we received funding from NordForsk, because it enabled us to achieve incredible breadth across the Nordic countries. As we had four different treatments that we wanted to compare, we needed 800 patients, and it wouldn’t have been possible to find that many test subjects just in one Nordic country. We needed to join forces to become large enough to carry out an experiment of this magnitude. By having more countries participate in the trial, our results can also apply more generally.”

The patients in the trial are of different ages, but rheumatoid arthritis most often strikes at the age of 50, and women are more prone to the condition than men. All the patients who participated in the study also had risk factors for developing severe progression of the condition.

“These patients were at risk of ending up in a wheelchair, so we took the worst segment of patients with rheumatoid arthritis, which presents our results in an even more positive light considering that such patients can get this far with the right treatment,” says Merete.

The first article that the project published, which was about the results after half a year of research, appeared in the British Medical Journal. At the same time, the project’s results have been included in the European guidelines for the treatment of rheumatoid arthritis.

“Having such a large Nordic project with such principled results helps to put the Nordics on the world map. That’s why I believe that the results of this study will shape the guidelines for the treatment of rheumatoid arthritis for decades to come. Many of the patients who’ve taken part in the project have told us about how bad they felt when they entered the project, and how incredibly happy they’ve been since. So the project is full of grateful participants.”


Maria Nilsson

Maria Nilsson

Special Adviser
Marianne Knudsen. Photo: NordForsk

Marianne Knudsen

Senior Communications Adviser