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Not Steroids Again To the Editor: I have a number of concerns with the editorial by Dr. Pincus, et al in the February issue of The Journal1. Firstly, Dr. Huizinga and his group have shown in an elegant study that methotrexate (MTX) has little influence on the smaller proportion of patients who may progress to rheumatoid arthritis but who have a negative test for anti-cyclic citrullinated peptide (CCP) antibodies2. This is a simple test to do; why not use it, rather than persisting in an approach that is unlikely to work? However, at worst this would result in a few patients getting MTX unnecessarily — not a major issue. My big concern is that they appear to be suggesting a return to the truly "bad old days" when family doctors would routinely prescribe steroids (alone) for their rheumatoid patients, and only refer after calamitous deformities develop — assuming the patients did not die of a heart attack beforehand. There is no evidence that steroids, whatever the dose, if given alone have any remittive qualities. I am not impressed by their impact even when given with disease modifying antirheumatic drugs (DMARD). The title clearly advocates steroids alone as an option for this undifferentiated disease. I think this is wrong, but what is worse is that to many family doctors, less skilled at recognizing joint swelling than Dr. Pincus and his colleagues, almost all rheumatoid is "undifferentiated" — at least without the anti-CCP test — and steroids will effectively remove the need for referral. ANTHONY RUSSELL, FRCPC, Rheumatic Disease Unit, University of Alberta, Edmonton, Alberta, Canada. 2. van Dongen H, van Aken J, Lard LR, et al. Efficacy of methotrexate treatment in patients with probable rheumatoid arthritis: a double-blind, randomized, placebo-controlled trial. Arthritis Rheum 2007;56:1424-32. [MEDLINE]
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