To the Editor:

We thank Drs. Graudal and Jürgens for their thoughtful letter concerning the recently published 2012 ACR recommendations for the treatment of RA. In a meta-analysis, Drs. Graudal and Jürgens showed similar effects of biologic agents with methotrexate versus combination DMARDs with prednisone on radiographic progression in RA (1). In their letter, the authors expressed concern about the cost of therapy with biologic agents versus combination DMARD therapy for early RA, as shown in Figure 1 of the article. The authors also point out additional evidence for the treatment of early RA from a meta-analysis (2) and a recent randomized controlled trial regarding similar clinical and radiographic efficacy of treatment with a biologic agent plus methotrexate versus combination DMARD therapy including triple therapy. Drs. Graudal and Jürgens are correct that cost issues were considered in the 2008 ACR recommendations (3) and were not commissioned by the ACR for the 2012 ACR RA recommendations update. The 2012 RA treatment recommendations update focused exclusively on the use of conventional DMARDs included in the prior recommendations, previously considered and new biologic DMARDs, switching between biologic agents, screening for tuberculosis with biologic agents, immunizations, and use in high-risk populations.

Figure 1 of the article shows that in early RA patients with high disease activity and a poor prognosis, the recommendation is to either use anti–tumor necrosis factor biologic therapy with or without methotrexate or combination DMARD therapy (such as double or triple therapy). Both are treatment options, with no prioritization or sequence to these options. Contextual factors, such as drug cost, comorbidity, and patient preferences (including the choice between oral versus injectable drugs and patient comfort level with potential adverse effects of drugs), will likely impact the decision regarding which of these 2 choices is made. As stated in the recommendations article, the best treatment decision is made in an individualized discussion between the patient and physician regarding the various options and with careful consideration of the risk/benefit ratio for the patient.

We also agree with Drs. Graudal and Jürgens that the field of RA therapeutics is evolving fast, and several new pieces of information are emerging. This implies that RA treatment recommendations will need to be periodically updated by the ACR to keep them relevant for the end users, including physicians and patients. Of note, the ACR recently disseminated the results of its Top 5 deliberations as part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign (, which expressly accounted for the value proposition in the management of RA (4). Some of the issues raised by the authors are addressed in that document. We thank the authors for raising an important point in their letter.

Jasvinder A. Singh MBBS, MPH*, Kenneth G. Saag MD, MSc*, Daniel Furst MD†, * University of Alabama, Birmingham, AL, † University of California, Los Angeles, CA.