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SIR, We welcome the collective efforts of Dr Chakravarty and colleagues [1] in producing current revised guidelines on the DMARD therapy in consultation with the British Association of Dermatologists. Undoubtedly a lot of attention and effort had gone into bringing these guidelines up to date. Active collaboration of the British Society for Rheumatology (BSR), British Health Professionals in Rheumatology (BHPR) and British Association of Dermatologists in a unified team capitalizes on diverse skills and ideas. We feel however that, when this theme is next re-visited the following concern should also be addressed. Concomitant use of MTX with radiotherapy had known to cause radiation recall dermatitis [2]. Radiation recall dermatitis refers to an inflammatory skin reaction at a previously irradiated field subsequent to chemotherapy administration. MTX is one of the agents reported to cause this phenomenon [2]. Recently, we have come across patients on established MTX therapy for inflammatory arthritis, who have had to be switched to an alternative DMARD after receiving radiotherapy for various malignancies. Food and Drug Administration (FDA) had issued warnings about possible soft tissue and osteonecrosis in this situation (www.fda.gov/CDER/foi/label/2004/11719slr106_ methotrexate_lbl.pdf). The risk exists for many years after the radiotherapy has been given and for these patients further MTX is contra-indicated. As there are no formal guidelines on this particular issue, future guideline developers should consider this not very uncommon patient population. When this guidance is next revised we suggest that input from an oncologist may be valuable and would help to broaden the guidance on DMARD therapy. Disclosure statement: The authors have declared no conflicts of interest.

rheumatology

Comment on: BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists