For all of these agents, there was a warning that the biologic (fill in your favorite) “… and methotrexate both increase immunosuppressive effects; risk of infection. High likelihood serious or life-threatening interaction. Contraindicated unless benefits outweigh risks and no alternatives available.” Nearly every study on biological agents ever published indicates that the benefits of combining a biologic with methotrexate always outweigh the risks. More importantly, for infliximab, the Food and Drug Administration–approved labeling states, “Remicade, used in combination with methotrexate, can reduce signs and symptoms, help stop further joint damage, and improve physical function in patients with moderately to severely active RA.”
This particular finding raises a number of questions, such as, “Who writes this stuff?” The authorship of these online resources is never clear. Is the information in all of the other databases as bad or worse? Is it possible that the information in these databases regarding the use, dose, toxicity, or drug interactions of all other drugs is of equally dubious veracity? Finally, might this disinformation campaign be deliberate?
In my more paranoid moments, I have even imagined that there is a conspiracy of drug companies trying to diminish the use of methotrexate in the treatment of rheumatic diseases by terminally irritating rheumatologists who prescribe the bulk of it so that we go directly to more expensive biologic agents as first-line drugs. In my alternative paranoid universe, I also imagine that malpractice lawyers are trying to develop the factual bases for a new round of malpractice suits because rheumatologists don’t get sued often enough.
How do we end the nightmare? I propose that we stop the pain using the power of the cloud by posting ratings of drug and disease databases on the ACR website. If that doesn’t work, we can HAQ into the offending database and change the entry. Failing that, we can even be old fashioned and use the telephone to provide the correct information. This time we will shout instead of whisper.
Dr. Cronstein is Paul R. Esserman Professor of Medicine at New York University School of Medicine, in New York City.
