Combination drug therapy retards the development of rheumatoid atlantoaxial subluxations

Objective. To compare the efficacy of combination therapy with disease-modi fying antirheumatic drugs (DMARDs) versus single therapy with DMARDs in the prevention of early cervical spine changes in patients with rheumatoid art hritis (RA). Methods. One hundred ninety-five patients with recent-onset RA (mean diseas e duration 8 months) were randomly assigned to receive a combination of DMA RDs (sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone) or a single DMARD with or without prednisolone, After 2 years of followup, cer vical spine radiographs were taken of 176 of these patients (85 in the comb ination-therapy group and 91 in the single-therapy group). These radiograph s were evaluated, and the findings were correlated with the therapy strateg ies as well as with peripheral joint destruction and clinical and laborator y 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. In terestingly, 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 sing le-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 s tatistically significant (P = 0.029). None of the patients with cervical sp ine changes achieved remission of RE during the study. Conclusion. In the present study, the incidence of cervical spine subluxati ons in patients treated with single-drug therapy was in accord with finding s of previous studies. However, none of the patients in the combination-the rapy group had aAAS or AAI, These findings suggest that early, aggressive c ombination-DMARD therapy with sulfasalazine, methotrexate, hydroxychloroqui ne, and prednisolone can prevent or retard the development of rheumatoid at lantoaxial disorders.