• methotrexate
• disease modifying antirheumatic drugs

We read with interest the report by Aletaha et al on international questionnaires of the early treatment of rheumatoid arthritis (RA).¹ We would like to draw attention to the newest statistics in Finland.

In Finland the sickness insurance scheme provides reimbursement (today 75%) for prescription drugs in chronic inflammatory rheumatic diseases, principally rheumatoid arthritis (RA), psoriatic arthritis, ankylosing spondylitis, chronic reactive arthritis, juvenile idiopathic arthritis, and systemic rheumatic diseases. Eligibility entails a medical certificate written by a specialist in rheumatology and approved by the welfare authorities. All patients who are entitled to reimbursement are centrally registered by the social insurance institution. Glucocorticoids and disease modifying antirheumatic drugs (DMARDs) are medicines which can be reimbursed in this category.

As the nationwide sickness insurance scheme covers the entire Finnish population of five million, it provides a good basis for an epidemiological survey of the occurrence of all rheumatic diseases and investigation of the use of various DMARDs by these patients.

In 2001 a total of 76 552 patients had an appropriate certificate entitling them to special reimbursement for DMARDs. Of this total, only 47 967 used the drugs listed in table 1. During 2001, 4325 new certificates were granted. Table 1 shows the numbers of users of glucocorticoids and of 12 DMARDs during the past seven years. A rapid rise can be seen in the numbers using methotrexate. In 2001 the number was 16 470, a third of all users, overtaking the previously most used drug sulfasalazine. The 40 year old drug, hydroxychloroquine, has been third most used drug since 1996. The traditional sulphoxide group drugs, sodium aurothiomalate, auranofin, and penicillamine, have lost 2860 of their earlier users (29%), whereas the newest drug, leflunomide, overtook cyclosporin in 2001. Half of the patients registered used glucocorticoids.

In Finland today rheumatic patients with specially reimbursed drugs have the code 202 on their national insurance card, but this code is the same for all rheumatic diseases. In her thesis in 1997 Kaipiainen-Seppänen counted that during four study years in a population of one million people, 3076 new patients had chronic inflammatory rheumatic disease and 491 connective tissue disease.² It can thus be calculated that around 16% of the patients in table 1 had connective tissue diseases.

Sulfasalazine was introduced in 1941, but the number of its users has continued to grow, albeit slowly, presumably owing to a sulphur allergy. Methotrexate has been for a decade the main drug used in RA globally, and it is also increasingly used in the spondyloarthropathies. Hydroxychloroquine is the preferred drug for systemic lupus erythematosus (SLE) and active Sjögren’s syndrome. However, the preponderance of these three drugs is also based on their frequent use in combination therapies. Finnish doctors are well informed of the Fin-RACo study in early RA: treatment with methotrexate, sulfasalazine, hydroxychloroquine, and prednisolone has proved more successful than single therapy.³ The recent report by Aletaha et al, based on two matched questionnaires in 1997 and 2000, shows the same trend as table 1.¹ The most commonly used DMARDs at the onset of RA were methotrexate and sulfasalazine, with their use still increasing, and antimalarial drugs.

Table 1 shows that the use of the alkylating agents, cyclophosphamide and chlorambucil, has slightly decreased. The reason for this might be the effectiveness of methotrexate in hindering the most severe complications of arthritic diseases like AA amyloidosis.⁴ New drugs continue to be needed, as witnessed by the rapid rise in figures for leflunomide.