Response to ‘Feasibility of tailored treatment based on risk stratification in patients with early rheumatoid arthritis’

Markusse and colleagues recently investigated whether rheumatoid arthritis patient subgroups formed according to the presence of poor prognostic factors respond differently to initial monotherapy or combination therapy [1]. Since both poorand good-prognosis subgroups experienced a better response to initial combination therapy, the authors concluded that patient-tailored treatment based on prognosis as suggested by the European League Against Rheumatism (EULAR) recommendations [2] is currently not feasible. As a general remark, the authors should be reminded that the EULAR recommendations primarily suggest combination of methotrexate with low-dose glucocorticoids because its efficacy is not surpassed by biologicals and it prevents overtreatment in 20 to 25 % of patients [3, 4]; delaying tumor necrosis factor-inhibitor initiation by 6 months does not affect outcomes [5]. Moreover, the definitions of poor prognosis (PP) used by Markusse and colleagues contrast with the stratification suggested by EULAR, which, as their paper’s supplementary files highlight, influences outcomes [2]. We therefore recommend that readers look at the supplementary information before drawing conclusions. Markusse and colleagues propose the presence of three of four characteristics as the definition of PP (erosions, rheumatoid factor/anti-citrullinated protein antibody combination, swollen joint count, elevated Disease Activity Score). In contrast, the definition of PP established by Visser and colleagues in the same trial population (sic) uses a different approach, namely C-reactive protein, erosion score and rheumatoid factor/anti-citrullinated protein