To the Editors:

We read with great interest the American College of Rheumatology (ACR) 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA), published in a recent issue of Arthritis Care & Research (1). We would like to compliment Saag and colleagues on the completion of this wide-ranging and difficult work. With this review in hand, rheumatologists around the world can make their choice of preferred (combination of) DMARDs or biologic agents to treat their patients with RA.

Remarkably, guidance on the use of one of the most often prescribed classes of drugs, the glucocorticoids, is nowhere to be found in these recommendations. Together with nonsteroidal antiinflammatory drugs, glucocorticoids are placed in the class of “antiinflammatory pharmacologic interventions,” and it is stated that “despite their frequent use in RA, were not part of the ACR charge or the purview of this endeavor and are not included in these recommendations” (1). We think that this is a major limitation of an otherwise very complete and well-researched document.

Many trials have shown the clinical effectiveness of both high- and low-dose glucocorticoids in the treatment of RA. For example, the Combinatietherapie Bij Reumatoïde Artritis (COBRA) trial and the BeSt study showed that a high oral pulse of prednisolone in combination with methotrexate and sulfasalazine is very effective and fast in lowering disease activity and delay of radiographic progression (2, 3). Likewise, the effectiveness of low-dose glucocorticoid treatment has been demonstrated, among others, by Kirwan et al (4), van Everdingen et al (5), in the BARFOT trial (6), and has been documented in 2 meta-analyses, one with Dr. Saag as the first author (7, 8). Additionally, a recent systematic review documented that glucocorticoids delay progression of joint damage on radiographs (9), and therefore should be regarded as disease-modifying therapy in RA.

Based on the currently available evidence, glucocorticoids can be regarded as highly effective therapy in patients with RA. We as a rheumatology community should focus on adequately balancing the benefits and risks of glucocorticoid therapy and perform the studies necessary to fill the knowledge gap. In the meantime, no RA treatment guideline is complete without a discussion of glucocorticoid therapy, both initially high-dose combination therapy and low-dose adjuvant therapy.

  • 1
    Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008; 59: 76284.
  • 2
    Boers M, Verhoeven AC, Markusse HM, van de Laar MA, Westhovens R, van Denderen JC, et al. Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis. Lancet 1997; 350: 30918.
  • 3
    Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, van Zeben D, Kerstens PJ, Hazes JM, et al. Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial. Arthritis Rheum 2005; 52: 338190.
  • 4
    Kirwan JR, and the Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study Group. The effect of glucocorticoids on joint destruction in rheumatoid arthritis. N Engl J Med 1995; 333: 1426.
  • 5
    Van Everdingen AA, Jacobs JW, Siewertsz van Reesema DR, Bijlsma JW. Low-dose prednisone therapy for patients with early active rheumatoid arthritis: clinical efficacy, disease-modifying properties, and side effects. A randomized, double-blind, placebo-controlled clinical trial. Ann Intern Med 2002; 136: 112.
  • 6
    Svensson B, Schaufelberger C, Teleman A, Theander J, for the BARFOT study group. Remission and response to early treatment of RA assessed by the Disease Activity Score. Rheumatology (Oxford) 2000; 39: 10316.
  • 7
    Saag KG, Criswell LA, Sems KM, Nettleman MD, Kolluri S. Low-dose corticosteroids in rheumatoid arthritis: a meta-analysis of their moderate-term effectiveness. Arthritis Rheum 1996; 39: 181825.
  • 8
    Gotzsche PC, Johansen HK. Meta-analysis of short-term low dose prednisolone versus placebo and non-steroidal anti-inflammatory drugs in rheumatoid arthritis. BMJ 1998; 316: 8118.
  • 9
    Kirwan JR, Bijlsma JW, Boers M, Shea BJ. Effects of glucocorticoids on radiological progression in rheumatoid arthritis. Cochrane Database Syst Rev 2007; 1: CD006356.

L. H. D. van Tuyl MSc*, W. F. Lems MD, PhD*, A. E. Voskuyl MD, PhD*, B. A. C. Dijkmans MD, PhD*, M. Boers MD, PhD*, P. J. S. M. Kerstens MD, PhD†, * VU University Medical Center, Amsterdam, The Netherlands, † Jan van Breemen Institute, Amsterdam, The Netherlands.