In a recent article, Yazici and colleagues used data from a survey of a relatively small number of rheumatologists to support the notion that a laboratory monitoring regimen for methotrexate (MTX)-treated patients with rheumatoid arthritis (RA) that is less intensive than that suggested by the American College of Rheumatology (ACR) is desirable (1). The lack of guidelines for monitoring patients receiving biologic compounds (anti–tumor necrosis factor and anti–interleukin receptor antagonist) was also noted in their report (1). The authors go on to suggest that the guidelines for monitoring MTX therapy need to be updated, and that guidelines for monitoring biologic compounds need to be drawn. Although we strongly agree with the second statement, we feel uncomfortable concluding, based on the data presented, that the ACR guidelines for monitoring MTX therapy need to be modified. Whereas these guidelines are far from being perfect, they are still the best we have; for persons unfamiliar with the original 1994 publication, the guidelines were derived from data based on sound methodology (2).
In a related matter, we want to point out that data gathered in a selected group of patients with RA (n = 313), who were followed up at less frequent intervals than those recommended by the ACR, and who only rarely presented abnormal liver function test abnormalities, were presented by Yazici et al at the 2003 annual meeting of the ACR (3). Unfortunately, these data have been quoted on the internet (e.g., eRheumatology News) as coming from the ACR, suggesting that the ACR guidelines are being “adjusted” (4). This, we think, is quite misleading to the clinician given that the ACR has not endorsed the conclusions presented in this abstract.
Is it possible that we have become too complacent in monitoring methotrexate therapy because we may not have personally witnessed a case of clinically significant liver disease? Changing the guidelines should be a meticulously data-driven process rather than based on the current practice patterns of a relatively small group of rheumatologists; at the conclusion of such a process, the guidelines may indeed be changed. If that is the case, we will be the first to welcome such change. Until then, we should use the guidelines as they are.