The recent article by Laan and colleagues [1] was interesting and thought provoking. However, a practicing physician must consider how this information, which was gathered after less than a year of treatment, applies to long-term management of patients with rheumatoid arthritis. Physicians are certainly aware that osteoporosis can result from glucocorticosteroids, but their use is unavoidable and essential in the initial management of some patients, especially those with severe, aggressive rheumatoid arthritis. If these drugs are not used, the patient's activity level tends to decrease with attendant psychological problems and diminution in quality of life.

I certainly agree with the desirability of tapering oral corticosteroids when they are no longer needed for management, but I fear that the article may unduly dissuade clinicians from using appropriate doses of corticosteroids for fear of trabecular bone loss in their patients. I have reviewed many medical records involving physicians who have found corticosteroid use necessary for their patients with various inflammatory disorders. The patients in question took legal action against their treating physicians when osteoporosis and other corticosteroid side effects developed. In looking at the difficult problem of managing patients with rheumatoid arthritis on a day-to-day basis, one must look at the entire picture, which could entail 20 or 30 years of treatment.

A low degree of physical activity (that is, a sedentary lifestyle) is an independent risk factor for osteoporosis. In the long run, would it not be better for patients to be judiciously treated with oral corticosteroids and enrolled in exercise programs or other activities than not to be given treatment because of fears of osteoporosis? Although I do not believe that the authors intended to say that corticosteroids are contraindicated, I am convinced that these findings could be taken out of context.