status from class III to class II, according to the Steinbrocker classification (10); this patient's early morning stiffness and erythrocyte sedimentation rate also improved appreciably. In the other 4 patients, however, functional class remained unchanged. These patients reported only a transient improvement in global status during the first 2 weeks of each treatment schedule despite improvements in early morning stiffness, erythrocyte sedimentation rate, rheumatoid factor levels, and platelet counts. Our inability to detect a statistically significant improvement was unlikely due to a low capacity for response in these patients, all of whom had active disease. All patients had some deformity resulting in disability; thus functional class and global assessments may have been measures too insensitive to record an improvement. Furthermore, we may not have detected a treatment effect because ofa Type II error. We considered it significant that none of the patients were willing to continue treatment at the conclusion of the study, despite the improvement in laboratory parameters. Except for the patient previously described (patient I), none believed that they had improved with treatment, and no patient was considered to have improved by the treating physicians. Thus, further study was not undertaken. The results of this small, uncontrolled pilot study are not encouraging, in essence because of the adverse effects of treatment. Despite its efficacy in rheumatoid vasculitis, intermittent intravenous pulse cyclophosphamide does not appear to be well tolerated in patients with refractory rheumatoid arthritis.
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