• Merete Lund Hetland, Espen A Haavardsholm, Anna Rudin, Dan Nordström, Michael Nurmohamed, Bjorn Gudbjornsson, Jon Lampa, Kim Hørslev-Petersen, Till Uhlig, Gerdur Grondal, Mikkel Østergaard, Marte S Heiberg, Jos Twisk, Kristina Lend, Simon Krabbe, Lise Hejl Hyldstrup, Joakim Lindqvist, Anna-Karin Hultgård Ekwall, Kathrine Lederballe Grøn, Meliha Kapetanovic, Francesca Faustini, Riitta Tuompo, Tove Lorenzen, Giovanni Cagnotto, Eva Baecklund, Oliver Hendricks, Daisy Vedder, Tuulikki Sokka-Isler, Tomas Husmark, Maud-Kristine Aga Ljoså, Eli Brodin, Torkell Ellingsen, Annika Söderbergh, Milad Rizk, Åsa Reckner Olsson, Per Larsson, Line Uhrenholt, Søren Andreas Just, David John Stevens, Trine Bay Laurberg, Gunnstein Bakland, Inge C Olsen, Ronald van Vollenhoven, and NORD-STAR study group.
• Copenhagen Center for Arthritis Research (COPECARE) and DANBIO, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark merete.hetland@dadlnet.dk.
• BMJ. 2020 Dec 2; 371: m4328.

ObjectiveTo evaluate and compare benefits and harms of three biological treatments with different modes of action versus active conventional treatment in patients with early rheumatoid arthritis.DesignInvestigator initiated, randomised, open label, blinded assessor, multiarm, phase IV study.SettingTwenty nine rheumatology departments in Sweden, Denmark, Norway, Finland, the Netherlands, and Iceland between 2012 and 2018.ParticipantsPatients aged 18 years and older with treatment naive rheumatoid arthritis, symptom duration less than 24 months, moderate to severe disease activity, and rheumatoid factor or anti-citrullinated protein antibody positivity, or increased C reactive protein.InterventionsRandomised 1:1:1:1, stratified by country, sex, and anti-citrullinated protein antibody status. All participants started methotrexate combined with (a) active conventional treatment (either prednisolone tapered to 5 mg/day, or sulfasalazine combined with hydroxychloroquine and intra-articular corticosteroids), (b) certolizumab pegol, (c) abatacept, or (d) tocilizumab.Main Outcome MeasuresThe primary outcome was adjusted clinical disease activity index remission (CDAI≤2.8) at 24 weeks with active conventional treatment as the reference. Key secondary outcomes and analyses included CDAI remission at 12 weeks and over time, other remission criteria, a non-inferiority analysis, and harms.Results812 patients underwent randomisation. The mean age was 54.3 years (standard deviation 14.7) and 68.8% were women. Baseline disease activity score of 28 joints was 5.0 (standard deviation 1.1). Adjusted 24 week CDAI remission rates were 42.7% (95% confidence interval 36.1% to 49.3%) for active conventional treatment, 46.5% (39.9% to 53.1%) for certolizumab pegol, 52.0% (45.5% to 58.6%) for abatacept, and 42.1% (35.3% to 48.8%) for tocilizumab. Corresponding absolute differences were 3.9% (95% confidence interval -5.5% to 13.2%) for certolizumab pegol, 9.4% (0.1% to 18.7%) for abatacept, and -0.6% (-10.1% to 8.9%) for tocilizumab. Key secondary outcomes showed no major differences among the four treatments. Differences in CDAI remission rates for active conventional treatment versus certolizumab pegol and tocilizumab, but not abatacept, remained within the prespecified non-inferiority margin of 15% (per protocol population). The total number of serious adverse events was 13 (percentage of patients who experienced at least one event 5.6%) for active conventional treatment, 20 (8.4%) for certolizumab pegol, 10 (4.9%) for abatacept, and 10 (4.9%) for tocilizumab. Eleven patients treated with abatacept stopped treatment early compared with 20-23 patients in the other arms.ConclusionsAll four treatments achieved high remission rates. Higher CDAI remission rate was observed for abatacept versus active conventional treatment, but not for certolizumab pegol or tocilizumab versus active conventional treatment. Other remission rates were similar across treatments. Non-inferiority analysis indicated that active conventional treatment was non-inferior to certolizumab pegol and tocilizumab, but not to abatacept. The results highlight the efficacy and safety of active conventional treatment based on methotrexate combined with corticosteroids, with nominally better results for abatacept, in treatment naive early rheumatoid arthritis.Trial RegistrationEudraCT2011-004720-35, NCT01491815.© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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