Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority trialBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1389 (Published 09 April 2015) Cite this as: BMJ 2015;350:h1389
All rapid responses
Kindly allow us to thank the authors for a comprehensive review of a disease activity guided, dose reduction strategy in 180 patients . All around the world, morbidity due to rheumatoid arthritis, as well as osteoarthritis, is increasing. With an increasing longevity, the absolute numbers perhaps are also increasing rapidly. We also know that there is also an increasing burden of lifestyle diseases, which may overlap at times with arthritis, giving rise to multiple comorbidities and polypharmacy, which surely isn’t good.
We see arthritis, rheumatoid as well as osteoarthritis, as a part of a spectrum with the end results being incapacitation, pain, stiffness, swelling around affected joints, decreased mobility, joint deformity, decreased joint space, and other radiological changes. Some overuse problems might coexist and may overlap. We do have a different approach and we concentrate on the symptoms. Taking the knees as an example, we have the “ASHA TECHNIQUE”, which we had told about some years ago [2-3]. Recurrences and flare ups may keep happening, and may be settled with another round of “ASHA TECHNIQUE”. We have found that once the swelling, stiffness and ROM (range of movement) is corrected, which can be done within a week or so, there is no further need of any medicines whatsoever, except for calcium, vitamin D, and / or ascorbic acid, if they are found deficient. Perhaps we need to be somewhat more conservative about our interpretations of radiological findings, as we feel that all those radiological features may continue to persist, despite a patient showing signs of marked relief. In our experience we have also seen some equally ‘bad’ x-rays, in asymptomatic patients and in ‘normal’ individuals.
We concentrate on just four aspects, the pain, swelling, stiffness and range of motion, and we are finding that our technique is quite helpful to an extent. This technique may not help everyone to the degree that they might prefer, or in very severe conditions . Certainly we feel that with much more research is needed to improve the efficacy, precision, etc, of our technique, so that the outcomes can be improved and sustained, and presently unable to do anything further, we leave it to the global medical and scientific fraternity to improve this technique. Perhaps in some patients, our technique can overcome the regular need of painkillers, and other disease modifying drugs, and can delay the need for a TKR (total knee replacement) indefinitely in those engaged in sedentary lifestyle or sedentary jobs.
• Dr (Lt Col) Rajesh Chauhan
Hon’ National Professor IMA CGP
• Dr. V.T.K. Titus
Professor and Head, Dept of Orthopaedics, CMC Vellore
• Dr. Sneha Titus
Professor, Dept of Paediatrics, CMC Vellore
• Dr. Ajay Kumar Singh Parihar
Index Medical College, Indore.
1. van Herwaarden Noortje, van der Maas Aatke, Minten Michiel J M, van den Hoogen Frank H J, Kievit Wietske, van Vollenhoven Ronald F et al. Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority trial. BMJ 2015; 350 :h1389
2. Chauhan R, Parihar AKS, Chauhan S, Chauhan SPS. Re: Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ 21 April 2013. Available at : http://www.bmj.com/content/345/bmj.e5339/rr/642114 (Accessed on 11 April 2015)
3. Chauhan R, Parihar AKS, Chauhan S, Chauhan SPS. Re: Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ 27 May 2013. Available at : http://www.bmj.com/content/345/bmj.e5339/rr/647313 (Accessed on 11 April 2015)
4. Chauhan R, Chauhan S, Parihar AKS. ‘Asha Technique’ for managing arthritis of knee. In : Innovative medical techniques showcased at international medical conferences. Lap Lambert Academic Publishing; 2014. p. 23 – 31.
Competing interests: The views expressed are those of the authors, and do not reflect any official policy, or position of any organization, association, or college.