Intended for healthcare professionals

Views & Reviews From the Frontline

Bad medicine: rheumatoid arthritis

BMJ 2011; 343 doi: (Published 05 October 2011) Cite this as: BMJ 2011;343:d6357
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

Inflaming the establishment is a civic duty, for medicine is a force not only for good but also for harm. The young learn to value experience only once they have gained it. In my experience there has been a dramatic decline in the severity of rheumatoid arthritis. Once common clinical signs such as ulna deviation are now rare, even on medical wards. Evidence supports my experience, with a halving of rheumatoid arthritis rates from 1955,1 and major declines in the rate of orthopaedic interventions.2 3 This reflects a change in the epidemiology and improvements in medical care.

But following decades of declining incidence, rheumatoid arthritis started to increase with the introduction in 1987 of new diagnostic criteria—the American College of Rheumatology criteria—and oddly only in women.1 There was no need for a positive rheumatoid factor nor elevated inflammatory indices to make a diagnosis of rheumatoid arthritis. Subjective features such as stiffness, pain, and synovitis became key. Recent guidelines from the National Institute for Health and Clinical Excellence (NICE) have gone further, suggesting that diagnosis should not be “constrained” by these criteria.4 NICE presses for early and urgent referral from general practice, even with normal investigations and limited symptoms. There is scant evidence to support this policy,5 and those on the development group (a group of 23, only two of whom were GPs) seem to have had little appreciation of the implications of such advice when 1 in 7 GP consultations are for musculoskeletal problems.6

The early use of disease modifying anti-rheumatic drugs (DMARDs) and in combination is also recommended. Since 2005 the number of drug prescriptions for DMARDs and new biological agents has doubled with a near tripling in costs to £40m annually.7 A profitable business. The 2012 British Rheumatology conference is currently seeking £400 000 in company sponsorship. But immunosuppressive treatments require regular monitoring and are associated with serious harms, including death.

In my experience, the diagnosis of RA is increasingly subjective, and based on soft clinical signs. Rheumatology also seems dependent on the use of “validated” questionnaire scoring systems. This approach relies on self reporting, but rheumatology need look no further than problems this has caused in pain management. These clinical scoring systems are intellectually bankrupt. Even within NICE guidelines there is an admission that there is “no evidence to support this approach . . . in mild synovitis,”4 raising the spectre of widespread overtreatment.

Are we overdiagnosing rheumatoid arthritis? A rising incidence following a background of decline, a rise seen only in women, and declining complications would strongly suggest that we are. Even within the literature there is recognition that 10-20% of rheumatoid arthritis has a fibromyalgic variant.8 Worse still, new criteria may potentially double rates of rheumatoid arthritis diagnosis in the coming years.9 Experience and evidence suggest that we are overdiagnosing and overtreating RA. Burdening the well with a life long diagnosis and polypharmacy is just bad medicine.


Cite this as: BMJ 2011;343:d6357


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