Re: Audit of shared care between hospital and general practice in the management of rheumatoid arthritis.

Re: Audit of Shared Care between Hospital and General Practice in the Management of Rheumatoid Arthritis SIR—I was interested to read the paper by Helliwell and O'Hara [1] on the audit of shared care between hospital and general practice in the management of rheumatoid arthritis (RA) using disease-modifying drugs. They point out that the audit for i.m. gold (sodium aurothiomalate) was disappointing because in only 26% of cases had the standard monitoring protocol been followed, and this poor result was attributed to not carrying out an annual chest X-ray as per protocol. The protocol was followed in 93% of cases for methotrexate, yet their protocol did not include an initial chest X-ray. Methotrexate pneumonitis is a hypersensitivity reaction to the drug with a not insignificant incidence of up to 4% [2]. Unfortunately, some patients do not recover fully and develop permanent fibrosing alveolitis, and a few also die. If a chest X-ray is not carried out pre-treatment, asymptomatic fibrosing alveolitis or other lung disease may be missed, and a subsequent chest X-ray showing abnormal appearances attributed to the drug in question with perhaps medico-legal consequences. There is evidence that pre-existing lung disease predisposes patients with RA to develop methotrexate pneumonitis [3], and the recent BSR guidelines now include a pre-treatment screening chest X-ray.