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Glucocorticoid Treatments and Rheumatoid Arthritis To the Editor: In the April issue of The Journal, Caplan, et al1 report a retrospective database analysis on glucocorticoid treatment in rheumatoid arthritis (RA). Their data show that a substantial proportion of the patients with RA are treated with prednisolone at any time during their course of disease. They also could show a correlation between the use of glucocorticoids and a poorer outcome of the disease. This seems not surprising, though, as one would expect the chance of doctors finding indication for prescribing glucocorticoids is greater among patients with the highest disease activity. In concordance with this, the authors themselves state that the association may be due to confounding by association. Other aspects of glucocorticoid treatment in rheumatoid patients are economic and demographic factors and the patients' attitudes to glucocorticoid treatment. These factors might influence the course of RA and the decision to use glucocorticoids or not. To my knowledge, the access to modern disease modifying antirheumatic drugs (DMARD) including biologic anti-tumor necrosis factor treatment is not in all countries equal at all levels of society. These factors might also influence another finding of Caplan, et al, namely that rheumatologists have different practices in prescribing glucocorticoids to their patients. This might to some extent be attributed to differences in economic, educational, and demographic characteristics of the patient populations. In their report, Caplan, et al do not specify whether intraarticular or intramuscular glucocorticoid injections were recorded and corresponding prednisolone doses estimated and included in the analysis. In most European rheumatologic centers I know of, parenteral glucocorticoid injections are often used as early bridge therapy to gain quick control over the rheumatic inflammation while the effect of DMARD is awaited, and to treat flares of disease activity. This might not be the case in the US, but if a substantial proportion of the patients in the study by Caplan, et al received parenteral glucocorticoids without this being recorded and included in the analysis, the conclusions of the study might be severely hampered. OLE SLOT, MD, Department of Rheumatology, Hvidovre Hospital, DK-2650 Hvidovre, Denmark. E-mail: ole.slot@hvh.regionh.dk REFERENCE 1. Caplan L, Wolfe F, Russell AS, Michaud K. Corticosteroid use in rheumatoid arthritis: Prevalence, predictors, correlates, and outcomes. J Rheumatol 2007;34:696-705. Epub 2007 Jan 15. [MEDLINE]
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