Bad medicine: rheumatoid arthritis

In a way all rheumatologists and our patients with RA should thank
Des Spence for his challenge to our views. He makes some clear
observations but finds it hard to find the answers, for the following
reasons.

His assertion that RA is becoming less common is difficult to answer
as the criteria we use now are very different to those of the 1950's. Back
then most forms of inflammatory arthritis were thought to be RA, which may
explain the different numbers and the variable outcomes.

His view that the disease is now milder is also impossible to answer
as treatment has improved dramatically, especially in the last 15 years.
How can we compare patients disease progression then with now?? Certainly
as rheumatolgists we can agree that joint deformity and the need for
surgery have all but disappeared, and that early diagnosis and treatment
is the key. As a clue we have some patients who have declined treatment over
the last decade or so. All are badly disabled or wheelchair bound, which
reminds us what a terrible disease untreated RA is.

Spence obviously feels a diagnosis of RA without a raised CRP and a
negative rheumatoid factor is questionable. In our practice this refers to
about 20% of new cases. If a test dose of corticosteroid (usually IM)
resolves the joint swelling and symptoms completely,and these symptoms and
signs recur within a few weeks in equal severity, this can be used as a
means of identifying patients who need longer term therapy. As Spence
alludes to, some of these patients would do well without methotrexate.
Hence if patients have been in remission for a year with negative tests
and radiology, a trial off treatment can then be employed again to assess
chronicity. Disease recurrence again identifies those who need longer term
treatment.

The safety of weekly methotrexate, with regular folate supplements
and blood monitoring is universally accepted. The expence of monitoring
has even lead to challenges as to whether it is cost effective to do it at
all. Here in Yorkshire we have successfully reduced testing to quarterly
in stable patients for over ten years now, without any reported problems.

Finally Spence has difficulty differentiating fibromyalgia from RA.
RA patients have joint pain, swelling and morning stiffness in a
characteristic distribution, which responds sensitively to
corticosteroids. Fibromyalgia patients lie awake all night and describe
constant pain affecting their whole body, with widespread tender points
and no response to corticosteroids. It is difficult to see how these two
conditions can be confused clinically.