Rheumatology 1999; 38: 905-906
© 1999 British Society for Rheumatology
Letters to the Editor |
The ARC steroid trial and its effect on clinical practice
Department of Rheumatology, Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, UK
Correspondence to:
R. Butler, Department of Rheumatology, Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, UK.
SIR, We read the recent article from the ARC low-dose glucocorticoid study group [1] on the effect of steroid withdrawal after 2 yr treatment in early RA with interest. The previous paper by Kirwan et al. [2] was widely publicized by the ARC in July 1995 and this included sending every general practitioner (GP) and rheumatologist in the UK a copy of the main findings of the study and recommendations regarding the use of a fixed dose of 7.5 mg prednisolone daily in patients with RA of <2 yr duration. We were interested to see whether this publicity had influenced GP prescribing habits, since some rheumatologists had reservations about the study and about the risk/benefit ratio of steroids in RA [3] in view of the well-recognized long-term toxicity of these drugs [4].
The records of all new patients who were referred by their GP to one of us (RB) between January 1994 and May 1998, and given a diagnosis of RA on their first clinic visit, were examined. Of 194 records identified, the diagnosis was confirmed and the case notes suitable for study in 169 cases. Sixty-seven of these were excluded because the GP had not made the diagnosis of RA before referral, five because they had received steroids for another condition and four because it was unclear whether the GP had prescribed steroids. The remaining 93 were divided into a pre-trial (37) and a post-trial (56) group on the basis of referral before or after July 1995. Sixty-six of these had hand radiographs available from their first visit. As shown in Table 1
, the groups were comparable.
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The use of steroids is shown in Table 2
. Few patients were given steroids, but, although the numbers are small, they clearly demonstrate that in the post-trial period there was a body of patients referred on 7.5 mg prednisolone that was not seen in the pre-trial period. These patients all came from different GP practices. Interestingly, four of the six patients exceeded the 2 yr disease duration criterion for steroid use suggested in the ARC mailing (1, 24, 48, 72, 96 and 516 months). There was also an increase in steroid use by the rheumatologist in this period, although the dose used was more variable.
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Our findings suggest that the publicity following the first report of the ARC steroid trial did have a modest effect on clinical practice. It is possible that the change in steroid use observed was fortuitous, or that GPs had become aware of the increased use of steroids by the rheumatologist at this time and used steroids more freely themselves. The new data demonstrate that steroid treatment needs to be continued beyond 2 yr to maintain benefit, although, as the authors acknowledge, questions remain as to the most appropriate way to use steroids in RA. Other data indicate that mailing information to doctors is, in isolation, an inefficient way to change practice [5]. Once a consensus is reached on the use of steroids in RA, it will be necessary to find a more effective way to modify clinical practice than that used by the ARC in 1995.
Notes
1 Present address: Department of Orthopaedics, Western Infirmary, Dumbarton Road, Glasgow G11, UK. 
References
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Hickling P, Jacoby RK, Kirwan JR et al. Joint destruction after glucocorticoids are withdrawn in early rheumatoid arthritis. Br J Rheumatol 1998;37:930–6.
[Abstract/Free Full Text] -
Kirwan JR and the ARC low-dose glucocorticoid study group. The effect of glucocorticoids on joint destruction in rheumatoid arthritis. N Engl J Med 1995;333:142–6.
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Morrison E, Capell H. Corticosteroids in the management of rheumatoid arthritis. [Editorial] Br J Rheumatol 1996;35:2–4.
[Free Full Text] - Saag KG, Koehnke R, Caldwell JR et al. Low dose long-term corticosteroid therapy in rheumatoid arthritis: an analysis of serious adverse events. Am J Med 1994;96:115–23.[ISI][Medline]
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Bero LA, Grilli R, Grimshaw JM et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. Br Med J 1998;317:465–8.
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