Rheumatology (Oxford) 2018; 57(2):309–17Tocilizumab (TCZ) therapy in DMARD-naïve patients with RA, is more effective at reducing erosion progression, particularly in the feet, compared with treat-to-target methotrexate (MTX) therapy. This analysis looked at radiographic joint damage, including separate examination of erosion progression and joint space narrowing (JSN) in the hands and feet of patients enrolled in the U-Act-Early trial. Radiographic damage is a common symptom of RA, with treat-to-target strategies aimed at preventing joint damage to improve patient outcomes. In this trial, 317 patients were equally randomised to receive TCZ + placebo MTX, MTX + placebo TCZ or TCZ + MTX doses. MTX dose was increased stepwise until treatment target (defined as sustained remission) was achieved. Once sustained remission was achieved, medication was tapered stepwise and then halted. Over the 2-year study period, Sharp-van der Heijde score and JSN were measured periodically to assess each patient’s radiographic joint damage. No significant differences in JSN in hands and feet were found between treatment strategies. Similar results were seen in erosion score, however, at 104 weeks, erosion progression in the feet was significantly less in patients given TCZ strategies compared with those given MTX alone. The results suggest that TCZ has a superior joint sparing effect compared with MTX, with TCZ therapy proving more effective in preventing erosion progression. The authors conclude that TCZ therapy reduces the likelihood of physical impairments in newly diagnosed patients with RA, which could improve the long-term clinical outcomes of these patients.