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Minocycline in Rheumatoid Arthritis

TO THE EDITOR: We congratulate Tilley and colleagues [1] on their well-designed and well-executed study. Their data and analysis are frustratingly difficult to find fault with, but we found it unusual that no direct measurement of pain was included. The disease in question was obviously mild, as shown by the low erythrocyte sedimentation rate, the small percentage of seropositive patients, the few patients with erosions, and the low Health Assessment Questionnaire scores. These findings might make the study's applicability to the wider population of patients with rheumatoid arthritis somewhat limited. We agree that minocycline is safe but question the conclusion on efficacy. It has been generally accepted by the North American and European outcome groups that a combination of variables giving a composite disease activity score is more valid, although which variables should be included has not yet been determined [2]. Pincus and colleagues [3] found that a simple self-report questionnaire shows a good correlation with many of the clinical outcome variables. Tilley and colleagues failed to show an improvement in functional or global assessment outcomes, by either patient or examiner. This finding is discordant with the improvements noted in joint swelling or tenderness. We estimate that seven patients would require minocycline for 48 weeks to obtain a 50% reduction in either joint swelling or tenderness, with no subjective improvement, in one patient [4]. The role of minocycline in the treatment of rheumatoid arthritis needs to be more clearly defined. At best, we feel that the drug will be an adjunctive rather than a useful alternative to available second-line drugs.