Intended for healthcare professionals

Letters Rheumatoid arthritis debate

Treatment of rheumatoid arthritis is good medicine

BMJ 2011; 343 doi: (Published 01 November 2011) Cite this as: BMJ 2011;343:d6962
  1. David L Scott, president1,
  2. John Hunter, honorary president2,
  3. Chris Deighton, president elect1,
  4. David G I Scott, past president1,
  5. David Isenberg, past president1
  1. 1British Society for Rheumatology, Bride House, London EC4Y 8EE, UK
  2. 2Scottish Society for Rheumatology, Edinburgh EH2 1JQ, UK
  1. d.scott1{at}

In “Bad medicine: rheumatoid arthritis” Spence combines unsupported assertions with misleading interpretations of publications about the disease.1

We agree that the severity of rheumatoid arthritis is declining. Strong evidence shows that this reflects better medical management, including early intensive treatment, and improved healthcare organisation.2 3

We disagree, however, with many other points. The diagnosis of rheumatoid arthritis is not “increasingly subjective.” The objective finding of joint swelling on examination is the key component of all classification criteria; ultrasound imaging provides confirmatory evidence.

We are not over-treating rheumatoid arthritis. The strong evidence base shows that treating active early disease intensively is beneficial; it was consequently recommended by all expert groups.2 Independent analysis by the National Audit Office highlights its economic benefits.4 All treatments incur risks, but evidence that immunosuppressive treatments increase serious harms is limited. The main risk is under-treatment. Historical data show high death rates in rheumatoid arthritis when access to specialists is limited and patients are referred late.5 The latest Cochrane overview shows biologics do not increase serious adverse events.6

The inadequately referenced data on medical costs is confused. The best current data, from the National Audit Office, show that in 2009 medical costs for treating rheumatoid arthritis in England were £557m (€636m, $892m).4 UK drug costs were much lower than French and German costs.

Spence implies that treating rheumatoid arthritis is “a profitable business” and comments on sponsorship of “the 2012 British Rheumatology conference.” Most major UK medical educational meetings have a range of sponsors. Sponsorship is highly regulated, and our society adheres to all existing guidelines and recommendations.

Spence starts his article by saying that inflaming the establishment is a civic duty. We believe that it is more likely to disadvantage and distress patients with a painful disabling disease. His column is not on “bad medicine”: it is a bad and inadequate review of the good medicine we practise.


Cite this as: BMJ 2011;343:d6962


  • Competing interests: DLS is president of the British Society for Rheumatology and was a member of the National Institute for Health and Clinical Excellence (NICE) Guideline Development Group on the management of rheumatoid arthritis; JH is honorary president of the Scottish Society for Rheumatology; CD is president elect of the British Society for Rheumatology and was clinical adviser on the NICE guideline; DGIS and DI are past presidents of the British Society for Rheumatology.


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