Laboratory aids in steroid therapy.

Cortisone and its analogues have been available in Great Britain for about 6 years. Despite extensive experience, it has not yet been possible to codify precisely either the indications for using these drugs or the method of regulating their dosage for maintenance therapy in the chronic rheumatic diseases. Nevertheless, the success or failure of treatment frequently depends on the refinements of these two factors. The problem is complicated by the fact that several of the traditional and objective criteria of disease activity are not relevant when using the steroid drugs. For example, Vaughan, Bayles, and Favour (1951) wrote: " . . . It will be wiser to use the sedimentation rate in parallel with the eosinophil count merely as an index of continued hormonal activity and not as a criterion of the effectiveness of therapy or disease activity." Bagnall (1951) reported a rise in the sedimentation rate of twelve patients, all of whom showed undoubted clinical improvement. Copeman and others (1952) further emphasized the unreliability of this test " . . . except as an indication of general trends". These workers have also pointed out that the degree of anaemia, as represented by the haemoglobin concentration, may no longer be used as a measure of disease activity. It may be profoundly influenced, especially in the early stages of treatment, by irrelevant and pharmacologically-induced phenomena. It is also true that these drugs invalidate several clinical criteria of the progress of the disease. For example, a gain in weight in a patient under treatment may be an ominous warning of sodium retention rather than an encouraging sign of diminished toxicity, and the suppression of a fever has to be interpreted quite differently from the occurrence of the same physical sign in an untreated patient. The prognosis ofrheumatoid arthritis is notoriously unpredictable. Since it is generally agreed that these powerful drugs should only be employed in patients in whom the disease might otherwise run a progressive or crippling course, there is, to quote Ragan, Demartini, Lamont-Havers, Jessar, Vaillancourt, and Grokoest (1952): " . . . a crying need for some definitive index of a poor prognosis early in the disease. If this were available, the tools are at hand to prevent invalidism at least for some years". The investigation here reported was designed to overcome some of these difficulties. It was also hoped to throw some light on the vexed problem of knowing when steroid therapy can be safely terminated. It is often difficult to know the extent to which the disease has gone into a natural remission as opposed to a drug-induced remission. A premature withdrawal of the drugs may have serious consequences which are difficult to reverse. Finally, it was hoped that one or more of these tests might prove helpful in "screening" the new drugs which are launched on to the market each year and for which "anti-rheumatic" properties are claimed.