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SIR, I was pleased to read the recent article on the short-term value of tocilizumab (TCZ) in decreasing the daily oral prednisone dose (DOPD) in RA patients in a real-life setting [1]. The proportion of RA patients receiving TCZ with a DOPD of 45 mg increased from 32% at baseline to 54% after 24 weeks and 12% were off prednisone at 24 weeks [1]. However, I have some concerns about the study design, the reporting and interpretation of the results. In the article [1], Table 2 did not report the results of the intention-to-treat analysis with last observation carried forward, since the patient numbers were different throughout the study period. The dropout rate of 19% and the use of the last observation carried forward could alter the statistical analysis between baseline DOPD and changes in either the DOPD or the 28-joint DAS with ESR (DAS28-ESR) at 24 weeks. Also, the DOPD was decreased at the physicians’ discretion throughout the study period, while the DAS28 had already plateaued at week 8. I wondered if the authors considered that the reduction in the DOPD during the study is mostly due to physician preference, introducing an important bias. Since physicians were expecting possible benefits of TCZ therapy, non-responders who had higher baseline DOPD also had the greatest reduction in the DOPD ( 7 mg) compared with moderate responders who had the least ( 2 mg) at 24 weeks. Lastly, the authors did not mention the use of IA CS in their study protocol, which could influence the DOPD [1]. Of interest, active use of IA injections in the case of synovitis and physician adherence to protocol increased the remission rate in early RA patients [2].

Comment on: Tocilizumab induces corticosteroid sparing in rheumatoid arthritis patients in clinical practice