3, middle). Results.Eighty-two patients participated (60% ACPA positive). In the aggressive group (n= 42), 19 patients were treated with adalimumab. In the conventional care group (n= 40), 24 patients started with hydroxychloroquin (HCQ), 2 with sulfasalazine (SSZ) and 14 with MTX. After 2 years, the median SHS increase was 0 [interquartile range (IQR) 01.1] and 0.5 (IQR 02.5), remission rates were 66 and 49% and HAQ decreased with a mean of 0.09 (0.50) and 0.25 (0.59) in the aggressive and conventional care group, respectively. All comparisons were nonsignificant. Conclusion.In patients with early arthritis of two to five joints, both aggressive tight-control therapy including adalimumab and standard therapy resulted in remission rates around 50%, low radiographic damage and excellent functional status after 2 years. However, full disease control including radiographic arrest in all patients remains an elusive target even in moderately active early arthritis. Trial registration.Dutch Trial Register,http://www.trialregister.nl/, NTR 144. Keywords:early arthritis, rheumatoid, TNF, treatment strategy, management, trial, STREAM == Introduction == The early and aggressive treatment of patients with RA is usually increasingly successful, particularly with combinations of DMARDs made up of anti-TNF therapy [15]. Among the results are percentages of sustained remission of 40%, excellent functional status and nearly total arrest of radiological damage progression. In an attempt to explain these better results than had been achieved before in RA of longer duration, the concept of a windows of opportunity was proposed, suggesting that early suppression of active inflammation produces long-term benefits [6]. Intensive therapy, preferably with a combination of drugs, therefore, is usually a well-established treatment strategy for patients with early active RA. However, the optimal strategy for patients presenting with only a few inflamed joints is not yet obvious. This category of patients is more difficult to study due to the problem CC2D1B of classifying these patients as having RA or undifferentiated arthritis (UA) [7]. In acknowledgement of this issue, a combined task pressure of ACR and EULAR has developed new classification criteria for RA [8]. One of the objectives of BINA these criteria is to increase the sensitivity for the diagnosis RA in early UA in order to facilitate the conduction of clinical trials in this category of patients. Other aspects to consider in trials in this group of patients are that around half of patients with UA will remit within 12 years [913], that it is inherently less possible to demonstrate a reduction of an already low disease activity, and finally that any toxicity of treatment is usually less acceptable since it is occurring in patients with only mildly active disease. In a preceding study, we have shown that patients with more severe forms of UA are under-treated in comparison with patients with RA [9]. One clinical trial has shown that UA patients treated with MTXvsplacebo have less progression to RA (according to 1987 ACR criteria [14]) and less progression of radiographic erosions, but these differences were confined to the subgroup of ACPA-positive patients [15]. On the other hand, BINA in early RA good results can also be obtained with the milder drug hydroxychloroquin (HCQ) [16]. The present 2-12 months trial [Strategies in Early Arthritis Management (STREAM)] investigated whether the approach of early aggressive therapy was also effective in arthritis patients presenting with only moderately active disease, i.e. in those patients who would not meet the usual inclusion criteria for trials in active RA. == Patients and methods == == Patients == Eligible patients were 18 years, with a symptom duration of 2 years. Additionally, they had to have two to five swollen joints and a total Sharpvan der Heijde radiographic score (SHS) [17] <5. Patients did not have to meet the 1987 ACR criteria for RA. Exclusion criteria were prior treatment with a DMARD, except for HCQ, the use of CSs in the last 3 months or an IA injection with CSs in the last month. In addition, patients with bacterial arthritis, crystal-induced arthritis, PsA, ReA, OA or arthritis due to sarcoidosis or another systemic autoimmune disease other than RA, as BINA well as pregnant patients and patients with a wish to conceive during the study were excluded. The patients were recruited from your rheumatology clinics of the Jan van Breemen Institute and the VU University or college Medical Center in Amsterdam, The Netherlands. The study was approved by the local institutional review table [Medisch Ethische Toetsingscommissie van Slotervaartziekenhuis en Reade.