Escalated conventional therapy for rheumatoid arthritis patients: reply

S. J. Bingham, M. H. Buch, A. Tenant and P. Emery

Academic Unit of Musculoskeletal Disease, Department of Rheumatology, Leeds, UK

Correspondence to: P. Emery, Academic Unit of Musculoskeletal Disease, Department of Rheumatology, 1st Floor, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK. E-mail: p.emery{at}leeds.ac.uk

We thank Dr Smith for his interest in our study. We were surprised to learn that the Australian government restricts anti-TNF-{alpha} therapies to patients who are seropositive for rheumatoid factor (RF). Although RF has been associated with the severity of erosions [1] and increased disability [2], a significant amount of disease activity and disability is still present in those patients without RF. Indeed, a study which matched seropositive and seronegative patients for disease duration and age found no significant differences between the two groups [3]. Nearly one-third of the 308 patients with severe refractory RA referred to our biological assessment clinic described in the paper were RF-negative [4]. Both RF-positive and -negative patients had severe active disease with a high level of disability (Table 1). Although the mean Health Assessment Questionnaire (HAQ) score and disease activity score (DAS28) were significantly lower in the RF-negative group, the mean DAS28 in both groups was well above the level required to prescribe biologicals in the UK (DAS28 ≥5.1).


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TABLE 1. Independent samples t-test

 
As outlined in our paper, patients were treated with escalated conventional therapy in order to identify those with truly resistant disease that should receive biologicals. Forty-four per cent of RF-negative patients did not respond satisfactorily to escalated conventional therapy and received biologicals by 1 yr. This was in fact a slightly higher proportion than in the cohort as a whole, in which 41% did not respond and received biologicals. There was no relationship between the presence of RF and receiving biologicals (Pearson's {chi}2 = 0.314).

In this large cohort of patients, erosion scores were not routinely measured. However, virtually all patients were erosive, making statistical analysis of the influence of the presence of erosions on receiving biological therapy irrelevant.

We feel that the presence of RF should not influence which patients should receive biologicals.

P.E. has acted as a consultant for Aventis and Pharmacia. The other authors have declared no conflicts of interest.

References

  1. Bukhari M, Lunt M, Harrison B, Scott D, Symmons D, Silman A. Rheumatoid factor is the major predictor of increasing severity of radiographic erosions in rheumatoid arthritis: results from the Norfolk Arthritis Register Study, a large inception cohort. Arthritis Rheum 2002;46:906–12.[CrossRef][ISI][Medline]
  2. Drossaers-Bakker K, Zwinderman A, Vliet Vlieland T et al. Long-term outcome in rheumatoid arthritis: a simple algorithm of baseline parameters can predict radiographic damage, disability, and disease course at 12-year follow-up. Arthritis Rheum 2002;47:383–90.[CrossRef][Medline]
  3. Panayi G, Celniska E, Emery P et al. Seronegative and seropositive rheumatoid arthritis similar diseases. Br J Rheumatol 1987;12:172–80.
  4. Bingham SJ, Buch MH, Tennant A, Emery P. The impact of escalating conventional therapy in rheumatoid arthritis patients referred for anti-tumour necrosis factor-{alpha} therapy. Rheumatology 2004;42:364–8.
Accepted 17 May 2004





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