Intended for healthcare professionals

Rapid response to:

Views & Reviews From the Frontline

Bad medicine: rheumatoid arthritis

BMJ 2011; 343 doi: (Published 05 October 2011) Cite this as: BMJ 2011;343:d6357

Rapid Response:

Response from the British Society for Rheumatology and the Scottish Society for Rheumatology

We are disappointed the BMJ published and indexed this article
internationally on Pubmed. It combines unsupported assertions with
misleading interpretations of published articles about rheumatoid
arthritis (RA).

It makes one correct point. The severity of established RA is
declining. There is strong evidence this reflects better medical
management, including early intensive treatment, and improved healthcare
organisation [1-3].

It includes many misleading claims. Firstly comments on
epidemiological research led by Sherine Gabriel at the Mayo Clinic are
incorrect [4,5]. She applied the same 1987 classification criteria to all
patients seen from 1955 onwards. She also found the incidence of RA was
similar if either older (1958) or newer (1987) criteria were used.

The diagnosis of RA is not "increasingly subjective". Joint swelling
on clinical examination, an objective clinical finding, is the key
component of all classification criteria for RA [6], with ultrasound
imaging now providing confirmatory evidence.

Fibromyalgic rheumatoid is not a potential misdiagnosis. It is a well
-defined subset of patients with established RA [7,8].

We are not overtreating RA. A very strong evidence-base has
established the benefits of treating active early RA intensively and it is
consequently recommended by all expert groups [9-12]. Independent analysis
by the National Audit Office highlights its economic benefits [13].

All treatments incur risks, but there is limited evidence
immunosuppressive treatments increase serious harms. The major risks come
from under-treatment. Historical data shows high death rates in RA when
access to specialists is limited [14] and when patients are referred late
[15]. In contrast the latest Cochrane overview shows biologics do not
increase serious adverse events [16].

The inadequately referenced data on medical costs is confused. The
best current data, provided by the National Audit Office, shows 2009
medical costs for treating RA in England were ?557M [13]. UK drug costs
were much lower than French and German costs.

Dr Spence implies treating RA is "a profitable business" and comments
about sponsorship of "the 2012 British Rheumatology conference". Most
major UK medical educational meetings have a range of sponsors, including
medical equipment and pharmaceutical companies. Sponsorship is highly
regulated and our specialist societies adhere to all existing guidelines
and recommendations.

Dr Spence describes his article as "inflaming the establishment as a
civic duty". We believe it is more likely to disadvantage and distress
patients with a painful disabling disease. His column is not "bad
medicine", it is bad and inadequate reviewing whilst we practice good

1. Uhlig T, Kvien TK. Is rheumatoid arthritis really getting less
severe? Nat Rev Rheumatol 2009; 5: 461-4.

2. Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet 2010;
376: 1094-108.

3. Ziegler S, Huscher D, Karberg K, Krause A, Wassenberg S, Zink A.
Trends in treatment and outcomes of rheumatoid arthritis in Germany 1997-
2007: results from the National Database of the German Collaborative
Arthritis Centres. Ann Rheum Dis 2010; 69: 1803-8.

4. Myasoedova E, Crowson CS, Kremers HM, Therneau TM, Gabriel SE. Is
the incidence of rheumatoid arthritis rising?: results from Olmsted
County, Minnesota, 1955-2007. Arthritis Rheum 2010; 62: 1576-82.

5. Gabriel SE, Crowson CS, O'Fallon WM. The epidemiology of
rheumatoid arthritis in Rochester, Minnesota, 1955-1985. Arthritis Rheum
1999; 42: 415-20.

6. Aletaha D, Neogi T, Silman AJ et al. 2010 Rheumatoid arthritis
classification criteria: an American College of Rheumatology/European
League Against Rheumatism collaborative initiative. Arthritis Rheum 2010;
62: 2569-81.

7. Ranzolin A, Brenol JC, Bredemeier M, Guarienti J, Rizzatti M,
Feldman D, Xavier RM. Association of concomitant fibromyalgia with worse
disease activity score in 28 joints, health assessment questionnaire, and
short form 36 scores in patients with rheumatoid arthritis. Arthritis
Rheum 2009; 61: 794-800.

8. Pollard LC, Kingsley GH, Choy EH, Scott DL. Fibromyalgic
rheumatoid arthritis and disease assessment. Rheumatology 2010; 49: 924-8.

9. Saag KG, Teng GG, Patkar NM et al. American College of
Rheumatology. American College of Rheumatology 2008 recommendations for
the use of nonbiologic and biologic disease-modifying antirheumatic drugs
in rheumatoid arthritis. Arthritis Rheum. 2008; 59: 762-84.

10. Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations
for the management of rheumatoid arthritis with synthetic and biological
disease modifying antirheumatic drugs. Ann Rheum Dis 2010; 69: 964-975.

11. Deighton C, O'Mahony R, Tosh J, Turner C, Rudolf M; Guideline
Development Group. Management of rheumatoid arthritis: summary of NICE
guidance. BMJ 2009; 338: 702.

12. Scottish Intercollegiate Guidelines Network Management of early
rheumatoid arthritis. A national clinical guideline. 2011.

13. National Audit Office. Services for people with rheumatoid
arthritis. Stationery Office, 2009.

14. Prior P, Symmons DP, Scott DL, Brown R, Hawkins CF. Cause of
death in rheumatoid arthritis. Br J Rheumatol 1984; 23: 92-9.

15. Symmons DP, Jones MA, Scott DL, Prior P. Longterm mortality
outcome in patients with rheumatoid arthritis: early presenters continue
to do well. J Rheumatol 1998; 25: 1072-7.

16. Singh JA, Wells GA, Christensen R, Tanjong Ghogomu E, Maxwell L,
Macdonald JK, Filippini G, Skoetz N, Francis D, Lopes LC, Guyatt GH,
Schmitt J, La Mantia L, Weberschock T, Roos JF, Siebert H, Hershan S, Lunn
MP, Tugwell P, Buchbinder R. Adverse effects of biologics: a network meta-
analysis and Cochrane overview. Cochrane Database Syst Rev 2011; 2:

Competing interests: David L Scott is President of the British Society for RheumatologyJohn Hunter is Honorary President of the Scottish Society for RheumatologyChris Deighton is President-Elect of the British Society for RheumatologyDavid GI Scott and David Isenberg are Past Presidents of the British Society for Rheumatology

13 October 2011
David L Scott
John Hunter, Chris Deighton, David GI Scott, David Isenberg
British Society for Rheumatology and Scottish Society for Rheumatology