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With great interest we read the viewpoint from Professor Landewé,1 calling for more caution, research and debate regarding the risks of overdiagnosis and overtreatment in rheumatology. Strongly agreeing with the overall message, especially that ‘(…) overtreatment is hardly discussed but likely present’, we would like to contribute to this discussion by raising an issue that touches base on two paradigms listed by Professor Landewé: remission and evidence-based rheumatology.
There is now ample evidence that a substantial proportion (12%–38%) of patients with rheumatoid arthritis (RA) do not achieve the status of remission according to disease activity indices, solely because of a patient global assessment (PGA) score >1 (0–10 scale, 10=worst).2 3 If the elevated score on PGA does not reflect disease activity, additional immunosuppressive agents cannot improve the status of these patients, as inflammation is already essentially abrogated. Elevated PGA, therefore, may induce the risk of overtreatment when applying disease indices or Boolean-based criteria to define the treatment aim, which is remission or at least low disease activity (LDA) according to current treatment recommendations.4 5 Naturally, patients who still report relevant disease symptoms despite the absence of significant inflammation need …
Handling editor Josef Smolen
Contributors RJOF and JAPdS wrote the draft of the manuscript and all coauthors revised it. The final version was approved by all coauthors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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