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Harris JT, Yang Y, Bentley JP, Chen Y, Ramachandran S. Estimation of optimal adherence threshold for tumor necrosis factor inhibitors in rheumatoid arthritis. Clin Rheumatol 2024; 43:2435-2444. [PMID: 38853227 PMCID: PMC11269320 DOI: 10.1007/s10067-024-06971-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/27/2024] [Accepted: 04/14/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Optimal adherence thresholds can vary across medications and disease states. The objective of the study was to determine the optimal threshold of the proportion of days covered (PDC) for tumor necrosis factor (TNF) inhibitors in patients with rheumatoid arthritis (RA). METHODS Patients with RA initiating self-administered TNF inhibitors were identified using 2012-18 Medicare fee-for-service claims. Time-varying PDC was calculated every day for the preceding 90 days during follow-up. Oral and injected glucocorticoid use, hospitalizations, emergency room (ER) visits, serious infections, and a composite of these were measured as outcomes. Time to first occurrence of each outcome as a function of time-varying PDC for TNF inhibitors was evaluated using Cox regression. Incident/dynamic time-dependent receiver operating characteristic curves and Youden's J index were used to obtain the optimal PDC threshold for outcomes at 365 days. RESULTS Of the 1190 patients who met the study inclusion criteria, almost 75% (865 patients) experienced at least one of the outcomes. Increasing PDC by 10% was significantly associated with decreased risks of the composite outcome (HR 0.98, 95% CI 0.96-1.00), oral glucocorticoid use (HR 0.93, 95% CI 0.91-0.96), and hospitalization (HR 0.96, 95% CI 0.94-0.99) but an increased risk of ER visits (HR 1.04, 95% 1.01-1.07). Optimal PDC thresholds for the composite outcome, oral glucocorticoid use, and hospitalization were 0.64, 0.59, and 0.56, respectively. CONCLUSIONS Increased PDC was associated with a decreased risk of adverse outcomes, except ER visits. The optimal PDC for TNF inhibitors in Medicare patients with RA based on clinical outcomes was about 60%. Key Points • The optimal proportion of days covered threshold for tumor necrosis factor inhibitors at 365 days based on clinical outcomes was found to be about 60%, which is lower than the traditional 80% used to define adherence. • Increased adherence was associated with decreased risks of oral glucocorticoid use, hospitalization, and the composite outcome. However, it was also associated with an increased risk of emergency room visits. • The mean time-varying 90-day proportion of days covered decreased throughout the study starting 92% at day 1 of follow-up to 62% at day 365.
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Affiliation(s)
| | - Yi Yang
- University of Mississippi, P.O. Box 1848, University, MS, 38677, USA
| | - John P Bentley
- University of Mississippi, P.O. Box 1848, University, MS, 38677, USA
| | - Yixin Chen
- University of Mississippi, P.O. Box 1848, University, MS, 38677, USA
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Favalli EG, Maioli G, Caporali R. Biologics or Janus Kinase Inhibitors in Rheumatoid Arthritis Patients Who are Insufficient Responders to Conventional Anti-Rheumatic Drugs. Drugs 2024:10.1007/s40265-024-02059-8. [PMID: 38949688 DOI: 10.1007/s40265-024-02059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/02/2024]
Abstract
Rheumatoid arthritis (RA) is a chronic immune-mediated inflammatory disease which can induce progressive disability if not properly treated early. Over the last 20 years, the improvement of knowledge on the pathogenesis of the disease has made available several drugs targeting key elements of the pathogenetic process, which now represent the preferred treatment option after the failure of first-line therapy with conventional drugs such as methotrexate (MTX). To this category of targeted drugs belong anti-cytokine or cell-targeted biological agents and more recently also Janus kinase inhibitors (JAKis). In the absence to date of specific biomarkers to guide the therapeutic choice in the context of true precision medicine, the choice of the first targeted drug after MTX failure is guided by treatment cost (especially after the marketing of biosimilar products) and by the clinical characteristics of the patient (age, sex, comorbidities and compliance) and the disease (presence or absence of autoantibodies and systemic or extra-articular manifestations), which may influence the efficacy and safety profile of the available products. This viewpoint focuses on the decision-making process underlying the personalized approach to RA therapy and will analyse the evidence in the literature supporting the choice of individual products and in particular the differential choice between biological drugs and JAKis.
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Affiliation(s)
- Ennio Giulio Favalli
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono, 7, 20122, Milan, Italy
- Department of Rheumatology and Medical Sciences, Gaetano Pini-CTO Hospital, P.zza Cardinal Ferrari 1, 20122, Milan, Italy
| | - Gabriella Maioli
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono, 7, 20122, Milan, Italy.
- Department of Rheumatology and Medical Sciences, Gaetano Pini-CTO Hospital, P.zza Cardinal Ferrari 1, 20122, Milan, Italy.
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono, 7, 20122, Milan, Italy
- Department of Rheumatology and Medical Sciences, Gaetano Pini-CTO Hospital, P.zza Cardinal Ferrari 1, 20122, Milan, Italy
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Omair MA, Alshehri MM, Altokhais NA, Aljanobi GA, El Dessougi MI, AlHarthi A, Omair MA, Attar SM, Bahlas SM, Alfurayj AS, Alazmi MS, Asiri AM, AlOmair MM, Al Juffali L, Almalag HM. Exploring Factors Influencing Medication Compliance in Saudi Rheumatoid Arthritis Patients: A Nationwide Cross-Sectional Survey - Results from the COPARA Study. Patient Prefer Adherence 2022; 16:1105-1114. [PMID: 35502428 PMCID: PMC9056069 DOI: 10.2147/ppa.s363477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Compliance is essential to achieve treatment goals in rheumatoid arthritis (RA) patients. The current study evaluated compliance and related factors in a large and diverse population. PATIENTS AND METHODS Patients with RA who received active treatment were invited to participate in an online survey. The Arabic versions of the 5-Item Compliance Questionnaire for Rheumatology (ACQR-5) and the RA Impact of Disease (RAID) were used to measure compliance and disability, respectively. The patients were sub-grouped based on background disease-modifying anti-rheumatic drugs (DMARDs). Variables associated with high compliance were selected for the logistic regression analysis. RESULTS A total of 1241 patients completed the survey and were included in the final analysis. Of those, 1055 (85%) were females with a mean (±SD) age and disease duration of 47.14 ± 13.71 and 8.77 ± 7.43 years, respectively. The mean RAID was 4.4±2.58, with 980 (79%) having an unacceptable level state. Patients with an unacceptable RAID level had a lower compliance rate (78.8% vs 85.8%, p = 0.001). Demographics associated with high compliance were female sex and increased age, with reported odds ratios of 1.018 (95% CI: 1.007-1.028) and 1.464 (95% CI: 1.016-2.108), respectively. Compliance was similar between patients on Janus kinase inhibitors or biological DMARDs (88.14% vs 80.83%, p = 0.17), between monotherapy, double therapy, or triple therapy recipients (80% vs 82.23% vs 81.32%, p = 0.665), and between patients receiving injectable and oral therapy (77.32% vs 81.14%, p = 0.246). CONCLUSION A high compliance level was observed in this population, with patient demographics influencing compliance rather than the medication type or route of administration. Interventional studies should focus on the of high-risk patients identified in this study.
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Affiliation(s)
- Mohammed A Omair
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Mohammed A Omair, Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia, Tel +966505270513, Email
| | - Maha M Alshehri
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | | | - Ghada A Aljanobi
- Rheumatology Unit, Department of Medicine, Qatif Central Hospital, Qatif, Saudi Arabia
| | - Maha I El Dessougi
- Rheumatology Unit, Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Amal AlHarthi
- Rheumatology Unit, Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Maha A Omair
- Department of Statistics and Operations Research, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Suzan M Attar
- Rheumatology Unit, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sami M Bahlas
- Rheumatology Unit, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdullah S Alfurayj
- Rheumatology Unit, Department of Medicine, Buraidah Central Hospital, Buraidah, Saudi Arabia
| | - Mansour S Alazmi
- Rheumatology Unit, Department of Medicine, Prince Mohammed Medical City, Sakaka-Aljouf, Saudi Arabia
| | - Alhussain M Asiri
- Rheumatology Unit, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Mohammed M AlOmair
- Rheumatology Unit, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Lobna Al Juffali
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Haya M Almalag
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Balsa A, García de Yébenes MJ, Carmona L. Multilevel factors predict medication adherence in rheumatoid arthritis: a 6-month cohort study. Ann Rheum Dis 2021; 81:327-334. [PMID: 34844924 DOI: 10.1136/annrheumdis-2021-221163] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/03/2021] [Indexed: 01/20/2023]
Abstract
Non-adherence challenges efficacy and costs of healthcare. Knowledge of the underlying factors is essential to design effective intervention strategies. OBJECTIVES To estimate the prevalence of treatment adherence in rheumatoid arthritis (RA) and to evaluate its predictors. METHODS A 6-month prospective cohort study of patients with RA selected by systematic stratified sampling (33% on first disease-modifying rheumatic drug (DMARD), 33% on second-line DMARD and 33% on biologics). The outcome measure was treatment adherence, defined by a score greater than 80% both in the Compliance Questionnaire in Rheumatology and the Reported Adherence to Medication scale, and was estimated with 95% CIs. Predictive factors included sociodemographic, psychological, clinical, drug-related, patient-doctor relationship related and logistic. Their effect on 6-month adherence was examined by multilevel logistic models adjusted for baseline covariates. RESULTS 180 patients were recruited (77% women, mean age 60.8). The prevalence of adherence was 59.1% (95% CI 48.1% to 71.8%). Patients on biologics showed higher adherence and perceived a higher medication need than the others; patients on second-line DMARDs had experienced more adverse events than the others. The variables explaining adherence in the final multivariate model were the type of treatment prescribed (second-line DMARDs OR=5.22, and biologics OR=3.76), agreement on treatment (OR=4.57), having received information on treatment adaptation (OR=1.42) and the physician perception of patient trust (OR=1.58). These effects were independent of disease activity. CONCLUSION Treatment adherence in RA is far from complete. Psychological, communicational and logistic factors influence treatment adherence in RA to a greater extent than sociodemographic or clinical factors.
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5
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Letarouilly JG, Salmon JH, Flipo RM. Factors affecting persistence with biologic treatments in patients with rheumatoid arthritis: a systematic literature review. Expert Opin Drug Saf 2021; 20:1087-1094. [PMID: 33926364 DOI: 10.1080/14740338.2021.1924146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Introduction: Biologic treatments are a milestone in the management of rheumatoid arthritis (RA) patients with an inadequate response to conventional synthetic treatments. With the increase in the number of biologic treatments, predictor factors of discontinuation are needed to choose the right treatment for the right patient.Areas covered: In this article, the factors affecting persistence with biologic treatments will be covered: factors associated with the demographic characteristics and comordidities of the patients, those with the characteristics of the disease, the biomarkers, and the adherence.Expert opinion: Seeking factors affecting persistence with biologic treatments is an important field of clinical research to offer the best management to the RA patients. Personalized medicine is the ultimate goal in this field to choose the biological therapy with the highest persistence for every patient. To achieve this goal, biomarkers could be a milestone.
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Affiliation(s)
| | - Jean-Hugues Salmon
- Department of Rheumatology, Université De Reims Champagne-Ardenne, Reims, France
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Núñez-Rodríguez J, González-Pérez Y, Nebot-Villacampa M, Zafra-Morales R, Obaldia-Alaña M, Caso-González A. Adherencia terapéutica a fármacos biológicos en pacientes con artritis reumatoide, artritis psoriásica y espondilitis anquilosante. (Estudio ADhER-1). Semergen 2021; 47:81-90. [DOI: 10.1016/j.semerg.2020.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/03/2020] [Accepted: 06/10/2020] [Indexed: 10/23/2022]
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Nieto JC, Arajol C, Carmona L, Marras C, Cea-Calvo L. Adherence to subcutaneous biological therapies in patients with inflammatory rheumatic diseases and inflammatory bowel disease: a systematic review. Immunotherapy 2021; 13:433-458. [PMID: 33557600 DOI: 10.2217/imt-2021-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Aim: To assess adherence to subcutaneous biologicals in adults with inflammatory rheumatic diseases or inflammatory bowel disease and evaluate factors possibly associated with adherence. Materials & methods: Systematic searches were conducted of main databases from January 2000 to June 2019. Results: 41 articles (32 full papers and nine abstracts) were included in the review. Among studies which used a medication possession ratio threshold of ≥80% as the end point, adherence varied from 28.8 to 89.4%. Possible predictors of adherence were older age, professional or family member support, belief in medication necessity, lower concerns about medication and monthly versus weekly administration. Conclusion: Considerable variability in adherence rates across published studies reflects study heterogeneity and the absence of a 'gold standard' to measure adherence.
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Affiliation(s)
- Juan C Nieto
- Department of Rheumatology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Claudia Arajol
- Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Loreto Carmona
- Instituto de Salud Musculoesquelética (InMusc), Madrid, Spain
| | - Carlos Marras
- Department of Rheumatology, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
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Abdul Razak S, Makmor Bakry M, Mohamed Said MS, Tan CE, Md Redzuan A. Development and Validation of Adherence Score for Subcutaneous Biologic Disease-Modifying Antirheumatic Drugs. Front Pharmacol 2020; 11:572260. [PMID: 33240088 PMCID: PMC7681069 DOI: 10.3389/fphar.2020.572260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 09/29/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The biologic disease-modifying antirheumatic drugs (bDMARDs) are currently incorporated as part of the pharmacotherapy management of inflammatory arthritis (IA). Adherence to bDMARDs is crucial to ensure treatment success in IA. However, most of the recent studies evaluated adherence level in patients using subcutaneous injections of bDMARDs utilized the indirect methods adapted from adherence assessment for oral medication. Aim: This study aimed to develop a questionnaire to assess adherence to the self-injectable subcutaneous bDMARDs. Methods: The development of the Subcutaneous bDMARDs Adherence Score (SCADS) involved evaluation of content validity. Literature reviews provide the basis for domain identification and item formation. Four experts evaluated the instrument by using a four-point ordinal scale with a rubric scoring on relevance, importance, and clarity of each item in measuring the overarching construct. The item-level content validity index (I-CVI) and the scale-level content validity index (S-CVI) were calculated. The factor structure and internal consistency reliability of SCADS were estimated using principal component analysis (PCA) and Cronbach's alpha, respectively. Results: Both S-CVI/UA (universal agreement) and the average item-level content validity index (S-CVI/Ave) (average) for the entire instrument showed excellent criteria with a value of >0.90. Cronbach's alpha coefficient value for SCADS was 0.707 indicating good internal consistency. All items showed corrected item-total correlation coefficients above 0.244. Questionnaire items with a factor loading of 0.30 or above were considered in the final factor solution. The factor analysis resulted in 3-factor solutions, which corresponded to 66.62% of the total variance. Conclusion: The SCADS is a consistent and reliable instrument for evaluating adherence among IA patients using the subcutaneous bDMARDs. It is simple to use, yet comprehensive but still requiring further clinical and international validation.
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Affiliation(s)
- Salmi Abdul Razak
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Tuanku Ja'afar Seremban, Seremban, Malaysia
| | - Mohd Makmor Bakry
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Chai-Eng Tan
- Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adyani Md Redzuan
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Fazaa A, Makhlouf Y, Ben Ouhiba A, Miladi S, Sellami M, Ouenniche K, Souabni L, Kassab S, Chekili S, Zakraoui L, Ben Abdelghani K, Laatar A. Adherence to biologic disease-modifying antirheumatic drugs in adult patients with rheumatic diseases. Therapie 2020; 76:467-474. [PMID: 32948325 DOI: 10.1016/j.therap.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/11/2020] [Accepted: 08/25/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The emergence of biologics has revolutionized the management of refractory rheumatic diseases (RD) by improving clinical outcomes. Unfortunately, the impact of non-adherence to the emerging therapy can limit their potential benefit. The objective of our study was to evaluate biologics' adherence in Tunisian patients with RD and to assess the determinants of non-adherence. METHODS We conducted a cross-sectional study involving patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) treated with bDMARDs (biologic disease-modifying antirheumatic drugs) for at least three months. Socio-demographic, clinical and biological data were collected. Biologic adherence was assessed using the compliance questionnaire for rheumatology (CQR). RESULTS One hundred patients with RD (45 RA and 55 SpA) were collected. Non-adherence to bDMARDs was found in 70% of cases. In univariate analysis, non-adherence to bDMARDs was statistically related to the absence of coxitis (P=0.003), to a low ASDAS-CRP (ankylosing spondylitis disease activity score) prior to the initiation of the bDMARDs (P=0.01), to a rate of administration of bDMARDs less than one injection per month (P=0.01), to the subcutaneous delivery route (P=0.02) as well as to non-adherence to csDMARDs (conventional disease-modifying antirheumatic drugs) (P=0.001). In multivariate analysis, the predictors of non-adherence were the absence of coxitis (OR=6.01; IC 95% [1.88-19.12]; P=0.002], and a rate of administration of bDMARDs less than one injection per month (OR=8.79; IC 95% [2.13-36.22]; P=0.003). CONCLUSION This work has revealed the low rate of adherence to biological treatments in Tunisian patient with RD. Predictors of poor adherence were the absence of coxitis and a rate of administration of bDMARDs less than one injection per month. Detection of these factors could help us to adapt our strategies to improve adherence that are essentially based on therapeutic education program.
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Affiliation(s)
- Alia Fazaa
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Yasmine Makhlouf
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia.
| | - Amad Ben Ouhiba
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Saoussen Miladi
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Mariem Sellami
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Kmar Ouenniche
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Leila Souabni
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Salma Kassab
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Selma Chekili
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Leith Zakraoui
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Kawther Ben Abdelghani
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
| | - Ahmed Laatar
- University Tunis El Manar, rheumatology department, Mongi Slim hospital, Sidi Daoued, 2046 La Marsa, Tunisia
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The Influence of Socio-Demographic Factors, Lifestyle and Psychiatric Indicators on Adherence to Treatment of Patients with Rheumatoid Arthritis: A Cross-Sectional Study. ACTA ACUST UNITED AC 2020; 56:medicina56040178. [PMID: 32295226 PMCID: PMC7230943 DOI: 10.3390/medicina56040178] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 12/27/2022]
Abstract
Background and Objectives: Rheumatoid arthritis (RA) is a severe autoimmune disease characterized by chronic inflammation of the joints accompanied by the progressive deformation and destruction of cartilage and joint bones. This study aims to gain insight into the outcomes related to adherence in patients with rheumatoid arthritis. Predicting the medication adherence in RA patients is a key point to improve the treatment outcome. Materials and Methods: A number of 119 Romanian patients with RA were included and divided into two groups: first group included 79 patients treated with conventional therapy and second group included 40 patients treated with biologic therapy. A CQR-9 (compliance questionnaire rheumatology with nine items) and PDSQ (psychiatric diagnostic screening questionnaire) were performed to assess correlations between medication adherence, patient sociodemographic variables, 11 psychiatric scales (major depressive disorder, posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder, psychosis, agoraphobia, social phobia, drug abuse/dependence, generalized anxiety disorder, somatization disorder, hypochondriasis) and lifestyle (bulimia, alcohol intake). Results: Whilst modelling factors associated with adherence, it was found that women and patients with higher education are more adherent. From the psychiatric indicators, only major depressive disorder and post-traumatic stress disorder were found to be positively correlated with therapeutic adherence. None of the assessed lifestyle factors influenced the adherence of RA patients. Conclusion: The knowledge of factors that impact on treatment adherence can be useful for clinicians to guide patient-centred care.
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Binder-Finnema P, Dzurilla K, Hsiao B, Fraenkel L. Qualitative Exploration of Triangulated, Shared Decision-Making in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2019; 71:1576-1582. [PMID: 30369071 PMCID: PMC6487233 DOI: 10.1002/acr.23801] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Treat-to-target implementation in rheumatoid arthritis (RA) requires a shared decision-making (SDM) process. However, ability to pay is a major determinant of patient choice, but how this factor affects SDM is under-explored. METHODS Visits at 4 RA clinics during which patients faced a decision to change their treatment were audiotaped between May 2016 and June 2017. Audiotapes were transcribed verbatim and analyzed using qualitative framework analysis. RESULTS A total of 156 visits were analyzed. Most patients with RA, except those with effective insurance coverage, had deliberations disrupted or sidelined by third-party insurance providers having power to authorize the preferred disease-modifying antirheumatic drug choice. This triangulated SDM complicated efficiency in deliberations and timely treatment and was a barrier to shared engagement about health risks and symptom improvement typically found in patient-provider dyads. CONCLUSION Rheumatology care providers should aim to incorporate treatment costs and ability to pay into their deliberations so that individualized out-of-pocket estimates can be considered during triangulated SDM at the point-of-care.
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Affiliation(s)
| | | | - Betty Hsiao
- Yale University School of Medicine, New Haven, Connecticut
| | - Liana Fraenkel
- Yale University School of Medicine, New Haven, Connecticut
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12
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The Giants (biologicals) against the Pigmies (small molecules), pros and cons of two different approaches to the disease modifying treatment in rheumatoid arthritis. Autoimmun Rev 2019; 19:102421. [PMID: 31733368 DOI: 10.1016/j.autrev.2019.102421] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 02/08/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that, if untreated, can lead to disability and reduce the life expectancy of affected patients. Over the last two decades the improvement of knowledge of the pathogenetic mechanisms leading to the development of the disease has profoundly changed the treatment strategies of RA through the development of biotechnological drugs (bDMARDs) directed towards specific pro-inflammatory targets involved in the RA network. To date, the therapeutic armamentarium for RA includes ten bDMARDs able to produce the depletion B-cells, the blockade of three different pro-inflammatory cytokines (tumour necrosis factor alpha, interleukin-6 and interleukin-1), or the inhibition of T-cell co-stimulation. The introduction of these new compounds has dramatically improved outcomes in the short and long term, although still a significant proportion of patients are unable to reach or maintain the treatment target over time. The identification of the fundamental role of Janus kinases in the process of transduction of the inflammatory signal within the immune cells has recently provided the opportunity to use the new pharmacological class of small molecules for the therapy of RA, further increasing the number of treatment options. In this review the PROS and CONS of these two drug classes will be discussed, trying to provide the evidence currently available to make the right choice based on the analysis of the efficacy and safety profile of the different drugs on the market and close to marketing.
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13
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Lauper K, Mongin D, Alpizar-Rodriguez D, Codreanu C, Iannone F, Kristianslund EK, Kvien TK, Pavelka K, Pombo-Suarez M, Santos MJ, Gabay C, Finckh A, Courvoisier DS. Drug retention of biological DMARD in rheumatoid arthritis patients: the role of baseline characteristics and disease evolution. Rheumatology (Oxford) 2019; 58:2221-2229. [DOI: 10.1093/rheumatology/kez221] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/11/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To examine the association of the evolution in physician-reported and patient-reported outcomes with decision to stop biological DMARDs (bDMARDs) in RA. The contribution of baseline characteristics is well established, but little is known about how the disease evolution influences the decision to discontinue therapy.
Methods
RA patients who initiated a bDMARD treatment from 2009 and with information on date of visit were pooled from seven European RA registers. Each outcome was divided into baseline assessments (capturing the inter-individual differences at drug initiation) and changes from baseline at subsequent visits (capturing the individual evolution). Cox regression models were used to examine their association with drug discontinuation, adjusting for baseline patient and co-therapy characteristics and stratifying by register and calendar year of drug initiation.
Results
A total of 25 077 patients initiated a bDMARDs (18 507 a TNF-inhibitor, 3863 tocilizumab and 2707 abatacept) contributing an amount of 46 456.8 patient-years. Overall, drug discontinuation was most strongly associated with a poor evolution of the DAS28, with a hazard ratio of 1.34 (95% CI 1.29, 1.40), followed by its baseline value. A change of Physician Global Assessment was the next strongest predictor of discontinuation, then the Patient Global Assessment.
Conclusions
The decision to discontinue treatments appears to be mostly influenced by DAS28 and particularly its evolution over time, followed by Physician Global Assessment evolution, suggesting that the decision to stop bDMARDs relies more on the physician’s than on the patient’s global assessment.
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Affiliation(s)
- Kim Lauper
- Division of Rheumatology, University Hospitals Geneva, Geneva, Switzerland
| | - Denis Mongin
- Division of Rheumatology, University Hospitals Geneva, Geneva, Switzerland
| | | | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania, Italy
| | | | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Karel Pavelka
- Institute of Rheumatology, Prague and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Manuel Pombo-Suarez
- Rheumatology Unit, Clinical University Hospital, University of Santiago de Compostela, Santiago, Spain
| | - Maria J Santos
- Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal, on behalf of Reuma.pt
| | - Cem Gabay
- Division of Rheumatology, University Hospitals Geneva, Geneva, Switzerland
| | - Axel Finckh
- Division of Rheumatology, University Hospitals Geneva, Geneva, Switzerland
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What are the risk factors of poor medication adherence in the target-to-treat era? Turk J Phys Med Rehabil 2019; 65:343-351. [PMID: 31893271 DOI: 10.5606/tftrd.2019.3071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/30/2018] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aims to identify adherence rate and risk factors of poor adherence in patients with tightly controlled rheumatoid arthritis (RA) based on the treat-to-target (TTT) strategy. Patients and methods In this cross-sectional, observational study, a total of 103 patients (22 males, 81 females; mean age 58.6±9.5 years; range, 35 to 76 years) with tightly controlled RA between November 2016 and May 2017 were included. The patients were evaluated in terms of sociodemographic features, smoking and alcohol drinking status, body mass index (BMI), Disease Activity Score 28 (DAS28), and clinical and medication data. They filled out a series of standardized questionnaires including the Morisky 8-item Medication Adherence Scale (MMAS-8), Beck Depression Inventory (BDI), Mini-Mental State Examination (MMSE), and Health Assessment Questionnaire-Disability Index (HAQ-DI). Multiple multivariate linear regression analysis was used to identify variables which were possibly associated with the MMAS-8. Results Of the patients, 53 (51.5%) were non-adherent and 50 (48.5%) were adherent to medication. The DAS28-erythrocyte sedimentation rate, mean DAS28, HAQ, BDI scores, and the number of visits were higher and the MMSE scores were lower in non-adherent patients than adherent patients. In the linear multivariate analysis, significant associations were found between the MMAS-8 and MMSE, BDI, DAS28, and mean DAS28 scores. Conclusion Our study results show that the medication adherence rate is significantly higher compared to previous studies and high disease activity, depression, and cognitive dysfunction significantly affect medication adherence in this patient population.
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15
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Smolen JS, Gladman D, McNeil HP, Mease PJ, Sieper J, Hojnik M, Nurwakagari P, Weinman J. Predicting adherence to therapy in rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis: a large cross-sectional study. RMD Open 2019; 5:e000585. [PMID: 30713716 PMCID: PMC6340591 DOI: 10.1136/rmdopen-2017-000585] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/31/2018] [Accepted: 11/04/2018] [Indexed: 12/17/2022] Open
Abstract
Objective This analysis explored the association of treatment adherence with beliefs about medication, patient demographic and disease characteristics and medication types in rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS) to develop adherence prediction models. Methods The population was a subset from ALIGN, a multicountry, cross-sectional, self-administered survey study in adult patients (n=7328) with six immune-mediated inflammatory diseases who were routinely receiving systemic therapy. Instruments included Beliefs about Medicines Questionnaire (BMQ) and 4-item Morisky Medication Adherence Scale (MMAS-4©), which was used to define adherence. Results A total of 3390 rheumatological patients were analysed (RA, n=1943; PsA, n=635; AS, n=812). Based on the strongest significant associations, the adherence prediction models included type of treatment, age, race (RA and AS) or disease duration (PsA) and medication beliefs (RA and PsA, BMQ-General Harm score; AS, BMQ-Specific Concerns score). The models had cross-validated areas under the receiver operating characteristic curve of 0.637 (RA), 0.641 (PsA) and 0.724 (AS). Predicted probabilities of full adherence (MMAS-4©=4) ranged from 5% to 96%. Adherence was highest for tumour necrosis factor inhibitors versus other treatments, older patients and those with low treatment harm beliefs or concerns. Adherence was higher in white patients with RA and AS and in patients with PsA with duration of disease <9 years. Conclusions For the first time, simple medication adherence prediction models for patients with RA, PsA and AS are available, which may help identify patients at high risk of non-adherence to systemic therapies. Trial registration number ACTRN12612000977875.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna and Hietzing Hospital, Vienna, Austria
| | - Dafna Gladman
- Department of Medicine, Toronto Western Hospital, Toronto, Ontario, Canada
| | - H Patrick McNeil
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Philip J Mease
- Department of Rheumatology, Swedish Medical Center and University of Washington, Seattle, Washington, USA
| | - Joachim Sieper
- Department of Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maja Hojnik
- Global Medical Affairs Rheumatology, AbbVie s.r.o., Ljubljana, Slovenia
| | - Pascal Nurwakagari
- Medical Department, AbbVie Deutschland GmbH & Co. KG, Wiesbaden, Germany
| | - John Weinman
- Institute of Pharmaceutical Science, King's College London, London, UK
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16
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Lauper K, Mongin D, Iannone F, Klami Kristianslund E, Kvien TK, Nordström D, Pavelka K, Pombo-Suarez M, Rotar Z, Santos MJ, Codreanu C, Lukina G, Courvoisier DS, Gabay C. Comparative effectiveness of subcutaneous tocilizumab versus intravenous tocilizumab in a pan-European collaboration of registries. RMD Open 2018; 4:e000809. [PMID: 30488002 PMCID: PMC6241977 DOI: 10.1136/rmdopen-2018-000809] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/16/2022] Open
Abstract
Objective To compare the real-word effectiveness of subcutaneous tocilizumab (TCZ-SC) and intravenous tocilizumab (TCZ-IV) in rheumatoid arthritis (RA). Methods Patients with RA with TCZ from eight European registries were included. Drug retention was compared using unadjusted Kaplan-Meier and Cox models adjusted for baseline patient, disease and treatment characteristics, using a strata term for year of treatment initiation and country of registry. The proportions of patients achieving Clinical Disease Activity Index (CDAI) remission and low disease activity (LDA) at 1 year were compared using samples matched on the same covariates and corrected for attrition using LUNDEX. Results 3448 patients were retrieved, 2414 with TCZ-IV and 1034 with TCZ-SC. Crude median retention was 3.52 years (95% CI 3.22 to 3.85) for TCZ-IV and 2.12 years for TCZ-SC (95% CI 1.88 to 2.38). In a country-stratified and year of treatment initiation–stratified, covariate-adjusted analysis, hazards of discontinuation were similar between TCZ-SC and TCZ-IV treated patients (HR 0.93, 95% CI 0.80 to 1.09). The average adjusted CDAI change at 1 year was similar in both groups (−6.08). After matching, with 560 patients in each group, CDAI remission corrected for attrition at 1 year was also similar between TCZ-SC and TCZ-IV (10.4% in TCZ-IV vs 12.8% in TCZ-SC (difference: 2.4%, bootstrap 95% CI −2.1% to 7.6%)), but CDAI LDA was lower in TCZ-IV patients: 41.0% in TCZ-IV versus 49.1% in TCZ-SC (difference: 8.0 %; bootstrap 95% CI 2.4% to 12.4%). Conclusion With similar retention and effectiveness, TCZ-SC is an adequate alternative to TCZ-IV for RA. When possible, considering the costs of the TCZ-IV route, TCZ-SC should be the preferred mode of administration.
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Affiliation(s)
- Kim Lauper
- Division of Rheumatology, Geneva University Hospitals, Geneva, Switzerland.,SCQM Registry, Zurich, Switzerland
| | - Denis Mongin
- Division of Rheumatology, Geneva University Hospitals, Geneva, Switzerland
| | - Florenzo Iannone
- Interdisciplinary Department of Medicine, Rheumatology Unit, GISEA, University Hospital of Bari, Bari, Italy
| | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Dan Nordström
- Department of Medicine, ROB-FIN, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Karel Pavelka
- Institute of Rheumatology, Prague and Clinic of Rheumatology Charles University, Prague, Czech Republic
| | - Manuel Pombo-Suarez
- Rheumatology Unit, Clinical University Hospital, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ziga Rotar
- Department of Rheumatology, BioRx.si, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Maria Jose Santos
- Rheumatology Department, on behalf of Reuma.pt, Hospital Garcia de Orta, Almada, Portugal
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Galina Lukina
- ARBITER, Institute of Rheumatology, Moscow, Russian Federation
| | | | - Cem Gabay
- Division of Rheumatology, Geneva University Hospitals, Geneva, Switzerland.,SCQM Registry, Zurich, Switzerland
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17
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Vogelzang EH, Hebing RCF, Nurmohamed MT, van Kuijk AWR, Kruijff JWF, l'Ami MJ, Krieckaert CLM, Wolbink G. Adherence to etanercept therapy in rheumatoid arthritis patients during 3 years of follow-up. PLoS One 2018; 13:e0205125. [PMID: 30300358 PMCID: PMC6177149 DOI: 10.1371/journal.pone.0205125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 09/19/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives To determine the percentage non-adherence to etanercept in patients with rheumatoid arthritis during three years of follow-up. Methods During study visits in this prospective cohort study, blood samples were taken to determine serum etanercept concentrations using ELISA and patients were asked if they had missed an etanercept dose, at which date and for what reason. Non-adherence was defined as serum etanercept concentration <0.1 μg/mL and no valid reason to miss the prescribed etanercept dose. Results In total, 292 consecutive patients treated with etanercept were included. Most patients had a valid reason to miss their etanercept dose (25/37). In total 12 out of 292 patients (4.1%, 95% confidence interval 2.2–7.2) were non-adherent during the 3 year period. In a small percentage of patients (3.4%, 95% confidence interval 0.8–10.4) who failed to respond to etanercept therapy, according to their rheumatologist, this was associated with inadequate exposure to etanercept and thus non-adherence. Conclusion In this study, adherence to etanercept therapy was measured using serum etanercept concentration. In most patients an absent etanercept concentration was due to a medical reason. Furthermore, the majority of patients were adherent to etanercept therapy and had adequate drug exposure. In total, only 12 out of 292 patients (4.1%) were non-adherent during 3 years of follow-up. These findings highlight that only a small minority of patients are non-adherent to etanercept treatment, especially compared to adherence rates of other drugs. However, physicians should be aware that in patients failing to respond to treatment, non-adherence is a possible cause.
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Affiliation(s)
- E H Vogelzang
- Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Amsterdam, The Netherlands
| | - R C F Hebing
- Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Pharmacy, Amsterdam, The Netherlands
| | - M T Nurmohamed
- Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Amsterdam, The Netherlands
| | - A W R van Kuijk
- Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Amsterdam, The Netherlands
| | - J W F Kruijff
- University of Amsterdam, Faculty of Science, Amsterdam, The Netherlands
| | - M J l'Ami
- Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Amsterdam, The Netherlands
| | - C L M Krieckaert
- Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Amsterdam, The Netherlands
| | - G Wolbink
- Amsterdam Rheumatology and Immunology Center
- Reade, Rheumatology, Amsterdam, The Netherlands.,Sanquin Research and Landsteiner Laboratory, Immunopathology, Amsterdam, The Netherlands
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Palominos PE, Gasparin AA, de Andrade NPB, Xavier RM, da Silva Chakr RM, Igansi F, Gossec L. Fears and beliefs of people living with rheumatoid arthritis: a systematic literature review. Adv Rheumatol 2018; 58:1. [DOI: 10.1186/s42358-018-0001-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/29/2018] [Indexed: 12/23/2022] Open
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