We read with interest the 2012 American College of Rheumatology (ACR) recommendations for the treatment of rheumatoid arthritis (RA) published recently in Arthritis Care & Research. The authors should be lauded for recommending combination disease-modifying antirheumatic drug (DMARD) therapy before the use of biologic agents in established RA, as shown in Figure 2 of the article (1). This recommendation is in contrast to the 2010 European League Against Rheumatism guidelines, which recommend biologic agents after the failure of 1 or 2 attempts with a single DMARD (2). However, the ACR recommendations also include biologic agents in the first line of treatment for early RA patients with a poor prognosis, as shown in Figure 1 of the article (1). Consideration of the price of treatment with biologic agents was mentioned in the 2008 ACR recommendations (3), but only concerned the patient's ability to pay for the treatment. We think it would be reasonable to also consider the public expense, especially in light of our recent meta-analysis (4) and a similar analysis by an independent group (5) that indicated that combination treatment with synthetic DMARDs and/or low-dose glucocorticoids is as efficient as a biologic agent combined with methotrexate. This finding has recently been confirmed in a new direct comparison of oral triple therapy versus etanercept plus methotrexate in early aggressive RA (6). Therefore, it should not be necessary to use biologic agents before the possibility of treatment with synthetic DMARDs has been exhausted, and it also should not be necessary to use biologic agents in patients with early RA and a poor prognosis. We are aware that the meta-analyses (4, 5) and the new study (6) were not available to the authors of the ACR recommendations (the literature search ended in February 2010). However, it would be interesting to learn what considerations the authors may have concerning a future revision of the ACR recommendations, especially in regard to the use of biologic agents as first-line treatment in early RA patients with a poor prognosis.
Dr. Jürgens receives royalties for her role as author of a textbook in clinical pharmacology.