Dear Dr. Helfgott:
Yesterday I received the June edition of The Rheumatologist and, in the evening, I read your paper with the title, “Minerals, Mud, Martinis, and Methylprednisolone” (p. 7), which I thoroughly enjoyed. I do think that we share the same views on several of the things you brought up.
Especially, I would like to point out that there is not a consensus between all European rheumatologists regarding the use of steroids in RA; quite a few share your skepticism, including myself. Many of our young colleagues accept the message from some authorities too easily; the young colleagues have not seen all the long-term consequences of steroid use that we have been exposed to (I have been a rheumatologist since the late 70s).
The article your refer to (Ann Intern Med. 2012;156:329-339) is one in a row with essentially the same findings, and there are several important issues that these and other authors ignore or only mention in passing. For instance, if one looks at the differences between the groups regarding joint-damage progression, it is obvious that the differences are small and only relate to erosion score and not to joint space narrowing. This is found also in other studies. Moreover, which, in fact, the authors point out, data after two years, whether the patients are still on steroids or not, are very scarce.
In Sweden, we have national guidelines (updated every year by the Swedish Rheumatological Society) and, according to my view, the recommendations unfortunately now include low-dose prednisolone in combination with methotrexate for early RA, which I do regret and fought to avoid during the processing of the drafts.
I do think it is a pity that the 2012 American guidelines (Arthritis Care Res. 2012;64:625-639) do not include anything about steroid use in early RA; that might have been a balancing factor for the discussion.
Tore Saxne, MD, PhD
Professor of Rheumatology
Lund University
Sweden
