[Early treatment of rheumatoid arthritis is useful. Emphasizing the importance of early referral to patients and doctors]. / Tijdige behandeling reumatoïde artritis is zinvol. Doordring patiënten en artsen van belang snelle verwijzing.

It is becoming clearer that early treatment of rheumatoid arthritis (RA) is useful. Recently, Dutch investigators observed a difference between RA referred early (within 12 weeks) and RA referred later (after 12 weeks). Patients who were referred earlier had a better prognosis, less damage on radiology, and a higher chance of going into remission. We discuss that these data support the importance of the early recognition of RA. Educating the public and establishing early arthritis clinics could help to prevent delay for both patient and doctor.

[Cost effectiveness of biologicals: high costs are the other face of success]. / Kosteneffectiviteit van biologicals. Hoge kosten zijn de keerzijde van het succes.

Where health care is concerned, the introduction of biologicals has greatly improved the treatment of chronic inflammatory disorders. This class of drugs is not only noticeably effective, but is also well tolerated. The cost effectiveness of these drugs means that there are limits to their use. This is the other face of success. The Dutch Ministry of Health, Welfare and Sport recently announced measures intended to limit the growth of costs while at the same time requiring that savings should be made on the current budget. Recently the Canadian Agency for Drugs and Technologies in Health (CADTH) produced a report on the effects and costs of biologicals for adults with rheumatoid arthritis (www.cadth.ca). Here we discuss their findings. Organizations for medical specialists should be societal aware and be able to deal with these drugs in a cost-conscious manner, including the development of dynamic guidelines and quality visitations.

[The multidisciplinary practice guideline "The responsible use of biologicals"]. / Multidisciplinaire richtlijn "Verantwoord gebruik van biologicals".

A multidisciplinary working group has developed a practice guideline containing various recommendations on the responsible and efficient use of biologicals. These biologicals include both soluble immune-receptor proteins and monoclonal antibodies that are aimed at immune mediators, receptors or cells. They are produced by biotechnology. Biologicals are used to treat patients with immune-mediated inflammatory disorders (IMIDs) such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis, juvenile idiopathic arthritis (JIA), psoriasis, ulcerative colitis, Crohn's disease, uveitis and sarcoidosis. This article summarises the most important recommendations contained in the practice guideline. The practice guideline is intended for members of the medical profession in addition to patients, who are considering, or are already, using biologicals.

[Polymyalgia rheumatica: new possibilities for treatment, but not diagnosis]. / Polymyalgia rheumatica. Nieuwe mogelijkheden voor behandeling, maar niet voor diagnostiek.

Polymyalgia rheumatica (PMR) is a chronic inflammatory rheumatic disorder, which predominantly occurs in patients aged 50 years and older. It can be difficult to differentiate PMR from other diseases, for general practitioners as well as for rheumatologists. Arteritis temporalis should not be overlooked in these patients, since missing this diagnosis may lead to irreversible visual loss. The majority of patients in whom PMR is suspected respond well to treatment with prednisone 15 mg per day. Methotrexate is an attractive alternative in patients who do not respond to prednisone or who experience side-effects due to prednisone.

[Insufficient evidence for oral glucocorticoids as first-line therapy for acute gout]. / Orale glucocorticoïden als behandeling van eerste keus van een acute jichtaanval onvoldoende onderbouwd.

In a recent equivalence clinical trial, prednisolone was reported to be equally effective as naproxen in the treatment of acute gout arthritis. The authors stated that the study provides a strong argument to consider prednisolone as first-line therapy for acute gout. For this double-blind placebo-controlled trial patients with the clinical diagnosis of acute gout (n = 381) were referred from primary care centers, but only those patients with crystal-proven gout and absence of contraindications for the trial medication were included (n = 120). They were randomly assigned to oral treatment for 5 days with either once-daily prednisolone 35 mg or twice-daily naproxen 500 mg and respective placebos. Points of discussion are whether there was indeed equivalence in effect, whether equivalence in adverse effects of the two treatments can be determined from the trial or from literature, and whether the results may be generalised. Although in selected acute gout patients prednisolone may be a good choice, available data still are too scarce to conclude that oral prednisolone is the first-line therapy for gout arthritis.

[Methotrexate: mainstay of rheumatoid arthritis treatment]. / Methotrexaat: hoeksteen van de behandeling van reumatoïde artritis.

Some accidents due to methotrexate (MTX) have been reported to the Dutch Health Authorities. However, for modern, intensive treatment of patients with rheumatoid arthritis and various other chronic autoimmune diseases, we cannot do without the drug, because of its broad applications and unique properties. Fortunately, it is a safe drug, if used by doctors experienced in using it and who follow MTX guidelines.

[Influenza vaccination of immunocompromised patients: safe and effective]. / Influenzavaccinatie van patiënten met verminderde afweer: veilig en effectief.

Influenza vaccination is important in order to limit flu-related morbidity and mortality. This especially applies to immunocompromised patients, such as HIV-infected individuals and patients on immunosuppressive treatment, who have an increased risk for developing complications from influenza. Influenza vaccine can be safely administered to all immunocompromised patients, but the effectiveness of the vaccine may be reduced. Uncertainty still exists concerning the value of an increased vaccine dose or booster vaccination: if positive effects exist, they are probably only of marginal clinical importance. Despite clearly reduced effectiveness, vaccination of immunocompromised patients is still valuable in view of the high absolute risk of infection and complications.

[Progress due to genetic research on rheumatoid arthritis: hype or hope?]. / Vooruitgang door genetisch onderzoek naar reumatoïde artritis: hype of hoop?

Thanks to progress in genetic research, various genetic factors involved in the pathogenesis of rheumatoid arthritis (RA) have been discovered.There is a difference in genetic risk factors for RA in patients with or without antibodies against cyclic citrullinated peptides. This has led to the idea that RA is not a single disease, but a heterogeneous syndrome. Currently known genetic risk factors are not suitable for prediction of the risk of individual patients developing RA, nor for early diagnosis, nor for determining the therapeutic strategy.Research into functional defects of gene products of genetic risk variants will increase the understanding of the pathogenesis of RA. This could lead to insights for the development of new specific medication.In the future, research into genetic factors correlated with the severity of RA disease progression or with the effect of antirheumatic medication is expected to yield interesting and hopefully clinically relevant results.