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Benefit/risk of therapies for rheumatoid arthritis: Underestimation of the "side effects" or risks of ra leads to underestimation of the benefit/risk of therapies

T. Pincus¹, A. Kavanaugh², T. Sokka^1,3

¹Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; ²The Center for Innovative Therapy, Division of Rheumatology, Allergy, and Immunology, University of California San Diego School of Medicine, La Jolla, California, USA; ³Jyvaskyla Central Hospital, Jyvaskyla, Finland.

ABSTRACT
Most physicians are familiar with the side effects or risks of drugs used to treat rheumatoid arthritis (RA), but relatively less familiar with the "side effects" or risks associated with RA itself. RA is not thought to have the same potential severity as a cardiovascular or neoplastic disease by most physicians, the public, or even some rheumatologists, although relative rates of predicted mortality in some patients with RA are in the range of some people with coronary artery disease or Hodgkin's disease.
Many reasons may be identified to explain why the risks of RA have been underestimated: RA does not lead to acute life-threatening situations; population-based data have suggested that most people who meet criteria for RA have a mild or self-limited process; acute attributed causes of death in people with RA are superficially similar to those in the general population; clinical trials have suggested many therapies that are efficacious over a period of 3-12 months; few long-term longitudinal studies were performed prior to the 1980s; medical recommendations made during the 1950s-1980s suggested that simple therapies were adequate for most patients; and quantitative information concerning patient status is generally not included in standard rheumatology care.
As more information has emerged concerning severe long-term outcomes in the "natural history" of RA (as treated prior to the 1990s), new strategies of aggressive intervention have been developed. Furthermore, basic research has led to new therapies. It appears that the benefit/risk ratio of therapies for RA has increased substantially over the last two decades, and the outlook for patients with RA is much better at this time than in previous years.

Key words
Rheumatoid arthritis, side effects, risks, benefit, therapy.

This study was supported in part by Abbott Immunology and Centocor.
Please address correspondence to: Theodore Pincus, MD, Professor of Medicine, Division of Rheumatology and Immunology, Vanderbilt University School of Medicine, 203 Oxford House, Box 5, Nashville, Tennessee 37232-4500, USA.