Inclusion of glucocorticoids in recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis: Comment on the article by Saag et al
Article first published online: 30 DEC 2008
Copyright © 2008 by the American College of Rheumatology
Arthritis Care & Research
Volume 61, Issue 1, pages 141–142, 15 January 2009
How to Cite
van Tuyl, L. H. D., Lems, W. F., Voskuyl, A. E., Dijkmans, B. A. C., Boers, M. and Kerstens, P. J. S. M. (2009), Inclusion of glucocorticoids in recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis: Comment on the article by Saag et al. Arthritis & Rheumatism, 61: 141–142. doi: 10.1002/art.24231
- Issue published online: 30 DEC 2008
- Article first published online: 30 DEC 2008
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.
- 3Clinical 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: 3381–90., , , , , , et al.
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.