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Dual target strategy: a proposal to mitigate the risk of overtreatment and enhance patient satisfaction in rheumatoid arthritis
  1. Ricardo J O Ferreira1,2,
  2. Mwidimi Ndosi3,4,
  3. Maarten de Wit5,6,
  4. Eduardo José Ferreira Santos1,2,7,
  5. Cátia Duarte1,8,
  6. Johannes W G Jacobs9,
  7. Pedro M Machado10,11,
  8. Désirée van der Heijde12,
  9. Laure Gossec13,14,
  10. Jose A P da Silva1,8
  1. 1 Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
  2. 2 Health Sciences Research Unit: Nursing (UICiSA:E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
  3. 3 Department of Nursing and Midwifery, University of the West of England, Bristol, UK
  4. 4 Academic Rheumatology Unit, University Hospitals Bristol, Bristol, UK
  5. 5 Patient Research Partner, EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
  6. 6 Department of Medical Humanities, Amsterdam University Medical Center, Amsterdam Public Health (APH), Amsterdam, The Netherlands
  7. 7 Escola Superior de Enfermagem do Porto, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
  8. 8 Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
  9. 9 Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, The Netherlands
  10. 10 Centre for Rheumatology and MRC Centre for Neuromuscular Diseases, University College London, London, UK
  11. 11 Rheumatology Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
  12. 12 Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands
  13. 13 Sorbonne Universités, UPMC University Paris 06, Institut Pierre Louis d’Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), Paris, France
  14. 14 Rheumatology Department, AP–HP, Pitié-Salpetrière Hospital, Paris, France
  1. Correspondence to Dr Ricardo J O Ferreira, Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra 3000-075, Portugal; rferreira{at}reumahuc.org

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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 …

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