• cyclosporin A
• early

We read the paper by Gerard et al with interest.¹ The authors are to be commended for the modest claims they make about the results of their study. They show that a combination of methotrexate and cyclosporin better retards radiographically visible progression than cyclosporin alone after one year in patients with early rheumatoid arthritis (RA). It raises the question whether cyclosporin A still has a place in the early treatment of this disease. One shortcoming of this study as stated in the paper is the lack of a methotrexate only arm. Furthermore, the study did not use optimal doses of methotrexate in the combined arm. Therefore, the possibility that the additional beneficial effects achieved in the combined arm at least in part might have been seen with methotrexate given in monotherapy cannot be excluded. The authors cite a number of studies supporting a retarding effect of cyclosporin, but fail to cite evidence that cyclosporin is not better than sodium aurothiomalate (Myocrisin) in this respect.² This study stratified for the use of corticosteroids, in contrast with another often cited paper which claims that cyclosporin is better than a number of comparative disease modifying antirheumatic drugs, including chloroquine.³ The three year follow up of the stratified study still showed no difference in radiographic progression between the arms. Despite strict adherence to safety rules about dosing of cyclosporin, adverse renal effects were seen, which were not completely reversible.⁴

The safety issue is, however, unsettled, …