Intended for healthcare professionals

Rapid response to:

Views & Reviews From the Frontline

Bad medicine: rheumatoid arthritis

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6357 (Published 05 October 2011) Cite this as: BMJ 2011;343:d6357

Rapid Response:

Authors Response 2

I sorry if these articles are taken personally, it is not my intent.
I write not for money nor status, but because I believe these are
important things to say. Also please don't blame the poor BMJ, they
employ me to write opinion pieces and that is what I do.

I am in no way trying to dismiss people suffering and I rather resent
this type of emotive response. Indeed I have never suggested early
treatment wasn't important nor effective. As for the article, which I
spent many hours researching, I believe it is factually correct. My point
was simply this we risk (are) over diagnosis and over treatment of RA.

As a full time GP to suggest that 1 in 3 consultations is related to
musculoskeletal disease is simply wrong. As for sponsorship, is ?400 000
for conference sponsorship for 500 consultants in the UK (sorry numbers
from Wikepedia on consultant numbers) excessive ? I am happy to spend
whatever it takes on medications that are effective, but medications
might be more affordable if companies spent less on marketing.

Assessing synovitis is subjective and although ultrasound can be used, how often and how widely is it actually used? Indeed what is the
positive predictive value of ultrasound anyway? Are you really suggesting
there is absolutely no overlap between the diagnosis of Fibromyalgia and
RA? If you can diagnosis RA with normal inflammatory makers and negative
RF, this simply doesn't seem credible. Do you really believe there is no
risk of overdiagnosis? Do you really believe there are no harms ?

Consider "the NPSA has identified 25 patient deaths and 26 cases of
serious harm linked to the use of oral methotrexate in a community setting
over a 10 year period in England ." [1] In a group of just 111 "One
patient in the routine group developed toxic epidermal necrolysis that was
secondary to sulfasalazine treatment, which resulted in permanent
bilateral corneal damage."[2] The rise in incidence was seen after 1987
after the introduction of new guidelines after decades of decline. This
was in women according to the paper. Why only in women, can you offer a
biological explanation?

But this is the bottom line. Please provide up to date incidence data
for RA in the UK over the last 2 decades (I searched but could not find
this). Please also provide comparative data between centres to see if
there is much variation in the incidence by clinic by clinic in the UK. A
rapid rise or significant regional variation on a the back of reduced
complications would suggest an over diagnosis effect. More medicine is not
always better medicine. I am very happy to attend a conference to defend
my views in person.

Lastly I will leave you the words not of uppity arrogant GP but
those of a consultant Rheumatologist .

"Dr. Raza, a senior lecturer and honorary consultant rheumatologist
at the University of Birmingham, cautioned however, that the use of the
updated RA criteria could lead to the overdiagnosis and subsequent
overtreatment of patients." [3]

[1] http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Patient-
Safety/500961/

[2] Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance R,
Kincaid W, Porter D.Effect of a treatment strategy of tight control for
rheumatoid arthritis (the TICORA study): a single-blind randomised
controlled trial. Lancet. 2004 Jul 17-23;364(9430):263-9.

[3] http://www.familypracticenews.com
/news/musculoskeletal-disorders/single-article/updated-
acreular-criteria-may-result-in-early-ra-overdiagnosis-
overtreatment/641bda1700.html

Competing interests: No competing interests

14 October 2011
Des Spence
GP
General Practice