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Factors influencing clinician prescribing of disease-modifying anti-rheumatic drugs for inflammatory arthritis: A systematic review and thematic synthesis of qualitative studies. Semin Arthritis Rheum 2022; 55:151988. [DOI: 10.1016/j.semarthrit.2022.151988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 11/23/2022]
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De Cock D, Buckinx E, Pazmino S, Bertrand D, Stouten V, Westhovens R, Verschueren P. Belgian rheumatologists' preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study. Rheumatol Int 2021; 42:815-823. [PMID: 34687348 DOI: 10.1007/s00296-021-05020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/02/2021] [Indexed: 12/01/2022]
Abstract
The reliability and clinical usefulness of the different composite disease activity scores and their individual components in Rheumatoid Arthritis (RA) are still debated. This study investigated which measures of disease activity were preferred by rheumatologists. A mixed-method study was performed. First, ten Belgian rheumatologists were invited for individual interviews on their current practice and preferences for measurement of RA disease activity. Results of this qualitative study and evidence from literature served as input for developing a survey. This survey asked rheumatologists to rate preferred standard disease activity score(s), their individual components, ultrasound and related patient-reported outcomes (PROs), by maximum difference scaling. The relative importance score (RIS) for each indicator was calculated using hierarchical Bayes modeling. The qualitative study included 6/10 invited rheumatologists. Composite scores and components were perceived as useful, while PROs were found subjective. Interestingly, ultrasound was used to mediate discrepancies between physician and patient. The survey based on this was sent to 244 Belgian rheumatologists, 83/244 (34%) responded, including 66/83 (80%) complete and 17/83 (20%) incomplete surveys (two missing essential information). Most rheumatologists (75/81, 93%) used a disease activity score and 68/81 (84%) preferred the DAS28-CRP. Swollen joint count obtained the highest mean ± SD RIS (22.54 ± 2.64), followed by DAS28 ESR/CRP (20.61 ± 4.06), ultrasound (16.47 ± 7.97), CRP (13.34 ± 6.11) and physician's global assessment (12.59 ± 7.83). PROs including fatigue, pain, and patient's global assessment, and Health Assessment Questionnaire, obtained the lowest mean RIS (0.34-2.54). Rheumatologists place more faith in self-assessed disease activity components or in laboratory tests. Trust in PROs to evaluate disease activity is low in clinical practice.
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Affiliation(s)
- D De Cock
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.
| | - E Buckinx
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - S Pazmino
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - D Bertrand
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - V Stouten
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - R Westhovens
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.,Department of Rheumatology, University Hospitals of Leuven, 3000, Leuven, Belgium
| | - P Verschueren
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.,Department of Rheumatology, University Hospitals of Leuven, 3000, Leuven, Belgium
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Tian X, Wang Q, Li M, Zhao Y, Zhang Z, Huang C, Liu Y, Xu H, Chen Y, Wu L, Su Y, Xiao W, Zhang M, Zhao D, Sun L, Zuo X, Lei J, Li X, Zeng X. 2018 Chinese Guidelines for the Diagnosis and Treatment of Rheumatoid Arthritis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2021; 2:1-14. [PMID: 36467901 PMCID: PMC9524773 DOI: 10.2478/rir-2021-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/04/2021] [Indexed: 02/05/2023]
Abstract
A multidisciplinary guideline development group was established to formulate this evidence-based diagnosis and treatment guidelines for rheumatoid arthritis (RA) in China. The grading of recommendations, assessment, development, and evaluation (GRADE) system was used to rate the quality of the evidence and the strength of recommendations, which were derived from research articles and guided by the analysis of the benefits and harms as well as patients' values and preferences. A total of 10 recommendations for the diagnosis and treatment of RA were developed. This new guideline covered the classification criteria, disease activity assessment and monitoring, and the role of disease modifying antirheumatic drugs (DMARDs), biologics, small molecule synthetic targeting drugs, and glucocorticoids in the treat-to-target approach of RA. This guideline is intended to serve as a tool for clinicians and patients to implement decision-making strategies and improve the practices of RA management in China.
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Affiliation(s)
- Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Zhiyi Zhang
- Department of Rheumatology, the First Affiliated Hospital Affiliated to Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Cibo Huang
- Department of Rheumatology, Beijing Hospital, Beijing, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Huji Xu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai, China
| | - Yaolong Chen
- Institute of Health Data Science, Lanzhou University, Chinese GRADE Center, Lanzhou, Gansu Province, China
| | - Lijun Wu
- Department of Rheumatology, Xinjiang Uygur Autonomous Region People's Hospital, Urumuqi, Xinjiang Uygur Autonomous Region, China
| | - Yin Su
- Department of Rheumatology, Peking University People's Hospital, Beijing, China
| | - Weiguo Xiao
- Department of Rheumatology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Miaojia Zhang
- Department of Rheumatology, The First Affiliated Hospital with Nanjing Medical University. Nanjing, JiangSu Province, China
| | - Dongbao Zhao
- Department of Rheumatology and Immunology, Changhai Hospital, The Second Military Medical University/Naval Medical University, Shanghai, China
| | - Linyun Sun
- Department of Rheumatology, Nanjing Drum Tower Hospital of Nanjing University Medical School
| | - Xiaoxia Zuo
- Department of Rheumatology and Immunology, Xiangya Hospital of Central South University, Rheumatic Diseases Research Center of Hunan Province, Changsha, China
| | - Junqiang Lei
- Department of Radiology, The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Xiaofeng Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), Beijing, China
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Van der Elst K, Verschueren P, Stouten V, Pazmino S, De Groef A, De Cock D, Joly J, Moons P, Westhovens R. Patient‐Reported Outcome Data From an Early Rheumatoid Arthritis Trial: Opportunities for Broadening the Scope of Treating to Target. Arthritis Care Res (Hoboken) 2019; 71:1566-1575. [DOI: 10.1002/acr.23900] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 04/02/2019] [Indexed: 11/12/2022]
Affiliation(s)
| | - Patrick Verschueren
- University Hospitals LeuvenKU Leuven, Catholic University of Leuven Leuven Belgium
| | | | - Sofia Pazmino
- KU Leuven, Catholic University of Leuven Leuven Belgium
| | - An De Groef
- KU Leuven, Catholic University of Leuven Leuven Belgium
| | | | - Johan Joly
- University Hospitals Leuven Leuven Belgium
| | - Philip Moons
- Catholic University of Leuven, Leuven, Belgium, University of Gothenburg, Gothenburg, Sweden, and University of Cape Town Cape Town South Africa
| | - René Westhovens
- University Hospitals LeuvenKU Leuven, Catholic University of Leuven Leuven Belgium
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Vandormael P, Verschueren P, De Winter L, Somers V. cDNA phage display for the discovery of theranostic autoantibodies in rheumatoid arthritis. Immunol Res 2016; 65:307-325. [DOI: 10.1007/s12026-016-8839-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Verschueren P, De Cock D, Corluy L, Joos R, Langenaken C, Taelman V, Raeman F, Ravelingien I, Vandevyvere K, Lenaerts J, Geens E, Geusens P, Vanhoof J, Durnez A, Remans J, Vander Cruyssen B, Van Essche E, Sileghem A, De Brabanter G, Joly J, Meyfroidt S, Van der Elst K, Westhovens R. Effectiveness of methotrexate with step-down glucocorticoid remission induction (COBRA Slim) versus other intensive treatment strategies for early rheumatoid arthritis in a treat-to-target approach: 1-year results of CareRA, a randomised pragmatic open-label superiority trial. Ann Rheum Dis 2016; 76:511-520. [DOI: 10.1136/annrheumdis-2016-209212] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 06/15/2016] [Accepted: 06/25/2016] [Indexed: 02/01/2023]
Abstract
ObjectivesCombining disease-modifying antirheumatic drugs (DMARDs) with glucocorticoids (GCs) is an effective treatment strategy for early rheumatoid arthritis (ERA), yet the ideal schedule and feasibility in daily practice are debated. We evaluated different DMARD combinations and GC remission induction schemes in poor prognosis patients; and methotrexate (MTX) with or without GC remission induction in good prognosis patients, during the first treatment year.MethodsThe Care in ERA (CareRA) trial is a 2-year investigator-initiated randomised pragmatic open-label superiority trial comparing remission induction regimens in a treat-to-target approach. DMARD-inexperienced patients with ERA were stratified into a high-risk or low-risk group based upon presence of erosions, disease activity, rheumatoid factor and anticitrullinated protein antibodies. High-risk patients were randomised to a COBRA Classic (MTX + sulfasalazine + prednisone step-down from 60 mg), COBRA Slim (MTX + prednisone step-down from 30 mg) or COBRA Avant Garde (MTX + leflunomide + prednisone step-down from 30 mg) scheme. Low-risk patients were randomised to MTX tight step-up (MTX-TSU) or COBRA Slim. Primary outcome was the proportion of patients in 28 joint disease activity score calculated with C-reactive protein remission at week 52 in an intention-to-treat analysis. Secondary outcomes were safety and effectiveness (ClinicalTrial.gov identifier NCT01172639).Results98 COBRA Classic, 98 COBRA Slim (high risk), 93 COBRA Avant Garde, 47 MTX-TSU and 43 COBRA Slim (low risk) patients were evaluated. Remission was achieved in 64.3% (63/98) COBRA Classic, 60.2% (59/98) COBRA Slim (high risk) and 62.4% (58/93) COBRA Avant Garde patients at W52 (p=0.840); and in 57.4% (27/47) MTX-TSU and 67.4% (29/43) COBRA Slim (low risk) patients (p=0.329). Less adverse events occurred per patient with COBRA Slim (high risk) compared with COBRA Classic or COBRA Avant Garde (p=0.038). Adverse events were similar in MTX-TSU and COBRA Slim (low risk) patients (p=0.871). At W52, 76.0% patients were on DMARD monotherapy, 5.2% used GCs and 7.5% biologicals.ConclusionsMTX with a moderate-dose GC remission induction scheme (COBRA Slim) seems an effective, safe, low-cost and feasible initial treatment strategy for patients with ERA regardless of their prognostic profile, provided a treat-to-target approach is followed.Trial registration numbersEudraCT-number 2008-007225-39 and NCT01172639; Results.
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Steunebrink LMM, Versteeg GA, Vonkeman HE, Ten Klooster PM, Kuper HH, Zijlstra TR, van Riel PLCM, van de Laar MAFJ. Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry. Arthritis Res Ther 2016; 18:60. [PMID: 26956382 PMCID: PMC4784382 DOI: 10.1186/s13075-016-0962-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 02/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treat to target (T2T) is widely accepted as the standard of care for patients with rheumatoid arthritis (RA) and has been shown to be more effective than traditional routine care. The objective of this study was to compare the effectiveness of two T2T strategies in patients with early RA: a step-up approach starting with methotrexate (MTX) monotherapy (cohort I) versus an initial disease-modifying antirheumatic drug combination approach (cohort II). METHODS A total of 128 patients from cohort II were case-control-matched with 128 patients from cohort I on gender, age, and baseline disease activity. Twelve-month follow-up data were available for 121 patients in both cohorts. The primary outcome was the proportion of patients having reached at least one 28-joint Disease Activity Score (DAS28) score <2.6 (remission) during 12 months of follow-up. Secondary outcomes were time until remission was achieved and mean DAS28 scores at 6- and 12-month follow-up. RESULTS After 12 months of follow-up, remission was reached at least once in 77.3 % of the patients in cohort II versus 71.9 % in cohort I (P = 0.31). Median time until first remission was 17 weeks in cohort II versus 27 weeks in cohort I (P = 0.04). A significant time by strategy interaction was found in mean DAS28 scores. Post hoc analysis revealed a significant difference in mean DAS28 scores between both cohorts at 6 months (P = 0.04), but not at 12 months (P = 0.36). CONCLUSIONS The initial combination strategy resulted in a comparable remission rate after 1 year but a significantly shorter time until remission. At 6 months, mean DAS28 scores were lower in patients with initial combination treatment than in those with step-up therapy. At 12 months, no significant differences remained in mean DAS28 scores or the proportion of patients in remission.
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Affiliation(s)
- L M M Steunebrink
- Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. .,Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - G A Versteeg
- Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. .,Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - H E Vonkeman
- Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. .,Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - P M Ten Klooster
- Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - H H Kuper
- Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands.
| | - T R Zijlstra
- Department of Rheumatology, Isala Klinieken, Zwolle, The Netherlands.
| | | | - M A F J van de Laar
- Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands. .,Department Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
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Verschueren P, Westhovens R. Separately tackling the development of erosions with denosumab: ultimately closing a gap in the treatment of patients with rheumatoid arthritis or trying too hard too late? Ann Rheum Dis 2016; 75:947-9. [PMID: 26861701 DOI: 10.1136/annrheumdis-2015-208863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/17/2016] [Indexed: 02/05/2023]
Affiliation(s)
- P Verschueren
- Department of Development and Regeneration KU Leuven, Skeletal Biology and Engineering Research Center, Leuven, Belgium Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - R Westhovens
- Department of Development and Regeneration KU Leuven, Skeletal Biology and Engineering Research Center, Leuven, Belgium Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
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Meyfroidt S, Stevens J, De Lepeleire J, Westhovens R, De Cock D, Van der Elst K, Vanhaecht K, Verschueren P. A general practice perspective on early rheumatoid arthritis management: A qualitative study from Flanders. Eur J Gen Pract 2015; 21:231-7. [PMID: 26679974 DOI: 10.3109/13814788.2015.1084279] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND General practitioners (GPs) may play a crucial role in early recognition, rapid referral and intensive treatment follow-up of patients with rheumatoid arthritis (RA). To improve early RA management, perceived barriers in general practice must be addressed. However, the general practice perspective on early RA management remains understudied. OBJECTIVE To explore GPs' experiences, beliefs and attitudes regarding detection, referral, and intensive treatment for early RA. METHODS In 2014, a qualitative study was conducted by means of individual, in depth, face-to-face interviews of a purposive sample of 13 Flemish GPs. Interviews were audio-recorded, transcribed verbatim and coded using the constant comparative method. RESULTS GPs applied multiple assessment techniques for early RA detection and regularly prescribed non-steroidal anti-inflammatory drugs if they suspected early RA. However, GPs felt unconfident about their detection skills because early RA symptoms are often unclear, diagnostic tests could provide inconclusive results and the incidence is low in general practice. GPs mentioned various approaches and multiple factors determining their referral decision. Perceived referral barriers included limited availability of rheumatology services and long waiting times. GPs considered intensive treatment initiation to be the expertise of rheumatologists. Reported key barriers to intensive treatment included patients' resistance and non-adherence, lack of GP involvement and unsatisfactory collaboration with rheumatology services. CONCLUSION GPs acknowledge the importance of an early and intensive treatment, but experience various barriers in the management of early RA. GPs should enhance their skills to detect early RA and should actively be involved in early RA care.
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Affiliation(s)
- Sabrina Meyfroidt
- a Department of Development and Regeneration , Skeletal Biology and Engineering Research Centre, KU Leuven , Leuven , Belgium
| | - Judith Stevens
- b Department of Public Health and Primary Care , Institute for Healthcare Management & Policy, KU Leuven , Leuven , Belgium
| | - Jan De Lepeleire
- c Department of Public Health and Primary Care , Academic Centre for General Practice, KU Leuven , Leuven , Belgium
| | - Rene Westhovens
- a Department of Development and Regeneration , Skeletal Biology and Engineering Research Centre, KU Leuven , Leuven , Belgium .,d Rheumatology , University Hospitals of Leuven , Leuven , Belgium , and
| | - Diederik De Cock
- a Department of Development and Regeneration , Skeletal Biology and Engineering Research Centre, KU Leuven , Leuven , Belgium
| | - Kristien Van der Elst
- a Department of Development and Regeneration , Skeletal Biology and Engineering Research Centre, KU Leuven , Leuven , Belgium .,d Rheumatology , University Hospitals of Leuven , Leuven , Belgium , and
| | - Kris Vanhaecht
- b Department of Public Health and Primary Care , Institute for Healthcare Management & Policy, KU Leuven , Leuven , Belgium .,e Department of Quality Management , University Hospitals of Leuven , Leuven , Belgium
| | - Patrick Verschueren
- a Department of Development and Regeneration , Skeletal Biology and Engineering Research Centre, KU Leuven , Leuven , Belgium .,d Rheumatology , University Hospitals of Leuven , Leuven , Belgium , and
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Buchbinder R, Maher C, Harris IA. Setting the research agenda for improving health care in musculoskeletal disorders. Nat Rev Rheumatol 2015; 11:597-605. [DOI: 10.1038/nrrheum.2015.81] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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De Cock D, Van der Elst K, Meyfroidt S, Verschueren P, Westhovens R. The optimal combination therapy for the treatment of early rheumatoid arthritis. Expert Opin Pharmacother 2015; 16:1615-25. [PMID: 26058860 DOI: 10.1517/14656566.2015.1056735] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune condition traditionally viewed as a severe destructive disease affecting physical health and global wellbeing. The treatment strategies for RA have changed in the last decades from mainly symptomatic towards a more vigorous and targeted approach. AREA COVERED Reviewing recent literature enhanced by own expertise and research, a case is made for starting early with an intensive combination treatment with glucocorticoids, followed by a treat to target approach in a tight control setting. Implementation issues that need to be addressed to make optimal use of the 'window of opportunity' are highlighted. EXPERT OPINION There is strong evidence in favor of traditional synthetic disease-modifying anti-rheumatic drugs (DMARDs) combined with a remission induction scheme of glucocorticoids to achieve adequate efficacy in controlling early rheumatoid arthritis with good safety and feasibility in daily clinical practice. Furthermore, the most optimal RA treatment should address not only the physician-oriented clinical disease outcomes but also the patient perspective. There is still a need for working on improving implementation of this approach in daily practice in order to provide optimal treatment benefit to more patients.
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Affiliation(s)
- Diederik De Cock
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration , Leuven , Belgium +016 346 350 ; +016 342 543 ;
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Verschueren P, De Cock D, Corluy L, Joos R, Langenaken C, Taelman V, Raeman F, Ravelingien I, Vandevyvere K, Lenaerts J, Geens E, Geusens P, Vanhoof J, Durnez A, Remans J, Vander Cruyssen B, Van Essche E, Sileghem A, De Brabanter G, Joly J, Van der Elst K, Meyfroidt S, Westhovens R. Patients lacking classical poor prognostic markers might also benefit from a step-down glucocorticoid bridging scheme in early rheumatoid arthritis: week 16 results from the randomized multicenter CareRA trial. Arthritis Res Ther 2015; 17:97. [PMID: 25889222 PMCID: PMC4422551 DOI: 10.1186/s13075-015-0611-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/26/2015] [Indexed: 01/06/2023] Open
Abstract
Introduction Considering a lack of efficacy data in patients with early rheumatoid arthritis (eRA) presenting without classical markers of poor prognosis, we compared methotrexate (MTX) with or without step-down glucocorticoids in the CareRA trial. Methods Disease-modifying antirheumatic drug–naïve patients with eRA were stratified into a low-risk group based on prognostic markers that included non-erosiveness, anti–citrullinated protein antibodies and rheumatoid factor negativity and low disease activity (Disease Activity Score in 28 joints based on C-reactive protein (DAS28(CRP)) ≤3.2). Patients were randomized to 15 mg of MTX weekly (MTX with tight step-up (MTX-TSU)) or 15 mg of MTX weekly with prednisone bridging, starting at 30 mg and tapered to 5 mg daily from week 6 (COmbinatie therapie bij Reumatoïde Artritis (COBRA Slim)). A TSU approach was applied. Outcomes assessed were DAS28(CRP)-determined remission, cumulative disease activity, Health Assessment Questionnaire (HAQ) scores and adverse events (AEs) after 16 treatment weeks. Results We analyzed 43 COBRA Slim and 47 MTX-TSU patients and found that 65.1% in the COBRA Slim group and 46.8% in the MTX-TSU group reached remission (P = 0.081). Mean ± standard deviation area under the curve values of DAS28(CRP) were 13.84 ± 4.58 and 11.18 ± 4.25 for the MTX-TSU and COBRA Slim patients, respectively (P = 0.006). More COBRA Slim patients had an HAQ score of 0 (51.2% versus 23.4%, P = 0.006) at week 16. Therapy-related AEs between groups did not differ. Conclusion In patients with low-risk eRA, MTX with step-down glucocorticoid bridging seems more efficacious than MTX step-up monotherapy, with a comparable number of AEs observed over the first 16 treatment weeks. Trial registration EU Clinical Trials Register Identifier: EudraCT number 2008-007225-39. Registered 5 November 2008. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0611-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patrick Verschueren
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Herestraat 49, 3000, Leuven, Belgium. .,Department of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Diederik De Cock
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Herestraat 49, 3000, Leuven, Belgium.
| | - Luk Corluy
- Reuma-Instituut Hasselt, Anne Frankplein 17, 3500, Hasselt, Belgium. .,Jessa Ziekenhuis Hasselt, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Rik Joos
- ZNA Jan Palfijn Antwerpen, Lange Bremstraat 70, 2170, Merksem, Belgium.
| | - Christine Langenaken
- Reuma-Instituut Hasselt, Anne Frankplein 17, 3500, Hasselt, Belgium. .,Jessa Ziekenhuis Hasselt, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Veerle Taelman
- Heilig Hart Ziekenhuis Leuven, Naamsestraat 105, 3000, Leuven, Belgium.
| | - Frank Raeman
- ZNA Jan Palfijn Antwerpen, Lange Bremstraat 70, 2170, Merksem, Belgium.
| | - Isabelle Ravelingien
- Department of Rheumatology, Onze-Lieve-Vrouw Ziekenhuis Aalst, Bloklaan 5, 1730 Asse, Aalst, Belgium.
| | - Klaas Vandevyvere
- AZ Groeninge Hospital Kortrijk, Pres. Kennedylaan 4, 8500, Kortrijk, Belgium.
| | - Jan Lenaerts
- Reuma-Instituut Hasselt, Anne Frankplein 17, 3500, Hasselt, Belgium. .,Jessa Ziekenhuis Hasselt, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Elke Geens
- ZNA Jan Palfijn Antwerpen, Lange Bremstraat 70, 2170, Merksem, Belgium.
| | - Piet Geusens
- ReumaClinic Genk & UHasselt, Jaarbeurslaan 21, 3600, Genk, Belgium. .,Maastricht UMC, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
| | - Johan Vanhoof
- ReumaClinic Genk & UHasselt, Jaarbeurslaan 21, 3600, Genk, Belgium.
| | - Anne Durnez
- AZ Groeninge Hospital Kortrijk, Pres. Kennedylaan 4, 8500, Kortrijk, Belgium.
| | - Jan Remans
- Reuma-Instituut Genk, Weg naar As 123, 3600, Genk, Belgium.
| | - Bert Vander Cruyssen
- Department of Rheumatology, Onze-Lieve-Vrouw Ziekenhuis Aalst, Bloklaan 5, 1730 Asse, Aalst, Belgium.
| | - Els Van Essche
- Imeldaziekenhuis Bonheiden, Imeldalaan 9, 2820, Bonheiden, Belgium.
| | - An Sileghem
- ReumaClinic Hasselt, Jaarbeurslaan 21, 3600, Genk, Belgium.
| | | | - Johan Joly
- Department of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Kristien Van der Elst
- Department of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Skeletal Biology and Engineering Research Center, KU Leuven Department of Public Health and Primary Care, Herestraat 49, 3000, Leuven, Belgium.
| | - Sabrina Meyfroidt
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Herestraat 49, 3000, Leuven, Belgium.
| | - Rene Westhovens
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Herestraat 49, 3000, Leuven, Belgium. .,Department of Rheumatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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13
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Meyfroidt S, Van der Elst K, De Cock D, Joly J, Westhovens R, Hulscher M, Verschueren P. Patient experiences with intensive combination-treatment strategies with glucocorticoids for early rheumatoid arthritis. PATIENT EDUCATION AND COUNSELING 2015; 98:384-390. [PMID: 25483574 DOI: 10.1016/j.pec.2014.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 10/15/2014] [Accepted: 11/10/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To investigate patients' experiences with intensive combination-treatment strategies with glucocorticoids (ICTS-GCs) in the early phase of early rheumatoid arthritis (ERA) treatment. METHODS We interviewed 26 participants individually, 4-6 months after initiation of ICTS-GCs (t1). Fourteen participants from the same sample took part in one of three focus groups at least 1 year after treatment initiation (t2). Each interview was audio-recorded, literally transcribed and thematically coded. RESULTS The participants described concerns and feelings about ICTS-GCs that changed over time; for example, a fear of side effects diminished when the treatment effects were beneficial or expected side effects did not materialize. Moreover, participants indicated additional information needs at t1 and t2. The most used sources of information were healthcare professionals, relatives, and the Internet. Furthermore, participants reported on their relationship with healthcare professionals and the need for trust and reassurance, especially at t1. Lastly, participants described their personal self-management strategies. CONCLUSION Despite their concerns at treatment initiation, most participants had positive experiences with ICTS-GCs. PRACTICE IMPLICATIONS Healthcare professionals should be aware that, in the early phase of treatment, they can address patients' concerns, they are the most important information source, they need to create a relationship of trust, and guide patients in self-management strategies.
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Affiliation(s)
- Sabrina Meyfroidt
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Kristien Van der Elst
- Center for Health Services and Nursing Research, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Diederik De Cock
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Johan Joly
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - René Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Marlies Hulscher
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patrick Verschueren
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Rheumatology, University Hospitals Leuven, Leuven, Belgium
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14
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A maximum difference scaling survey of barriers to intensive combination treatment strategies with glucocorticoids in early rheumatoid arthritis. Clin Rheumatol 2015; 34:861-9. [PMID: 25711874 DOI: 10.1007/s10067-015-2876-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/26/2014] [Accepted: 01/13/2015] [Indexed: 10/23/2022]
Abstract
The objectives of the study were to determine the relative importance of barriers related to the provision of intensive combination treatment strategies with glucocorticoids (ICTS-GCs) in early rheumatoid arthritis (ERA) from the rheumatologists' perspective and to explore the relation between rheumatologists' characteristics and importance scores. A maximum difference scaling (MDS) survey was administered to 66 rheumatologists in Flanders and the Brussels-Capital Region. The survey included 25 barriers, previously being discovered in a qualitative study. The survey included 25 choice sets, each of which contained a different set of four barriers. In each choice situation, respondents were asked to choose the most important barrier. The mean relative importance score (RIS) for each barrier was calculated using hierarchical Bayes modeling. The potential relation between rheumatologists' characteristics and the RIS was examined using Spearman's correlation coefficient, Mann-Whitney U test, and Kruskal-Wallis H test. The three highest ranked barriers included "contraindicated for some patients (e.g., patients with comorbidities, older patients)," "an increased risk of side effects and related complications," and "patients' resistance" with a mean ± SD RIS of 9.76 ± 0.82, 8.50 ± 1.17, and 7.45 ± 1.22, respectively. Comparing the RISs based on rheumatologists' characteristics, a different ranking was found for three barriers depending on the age, university location, and/or frequency of prescribing ICTS-GCs. The dominant barriers hindering ICTS-GCs prescription from a rheumatologists' perspective are patient-related barriers and barriers related to the complexity of prescribing a combination therapy including GCs. A tailored improvement intervention is needed to overcome these barriers and should focus on the familiarity of rheumatologists with ICTS-GC and patient education.
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15
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Verschueren P, De Cock D, Corluy L, Joos R, Langenaken C, Taelman V, Raeman F, Ravelingien I, Vandevyvere K, Lenaerts J, Geens E, Geusens P, Vanhoof J, Durnez A, Remans J, Vander Cruyssen B, Van Essche E, Sileghem A, De Brabanter G, Joly J, Meyfroidt S, Van der Elst K, Westhovens R. Methotrexate in combination with other DMARDs is not superior to methotrexate alone for remission induction with moderate-to-high-dose glucocorticoid bridging in early rheumatoid arthritis after 16 weeks of treatment: the CareRA trial. Ann Rheum Dis 2014; 74:27-34. [DOI: 10.1136/annrheumdis-2014-205489] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
ObjectivesTo compare the efficacy and safety of intensive combination strategies with glucocorticoids (GCs) in the first 16 weeks (W) of early rheumatoid arthritis (eRA) treatment, focusing on high-risk patients, in the Care in early RA trial.Methods400 disease-modifying antirheumatic drugs (DMARD)-naive patients with eRA were recruited and stratified into high risk or low risk according to classical prognostic markers. High-risk patients (n=290) were randomised to 1/3 treatment strategies: combination therapy for early rheumatoid arthritis (COBRA) Classic (methotrexate (MTX)+ sulfasalazine+60 mg prednisone tapered to 7.5 mg daily from W7), COBRA Slim (MTX+30 mg prednisone tapered to 5 mg from W6) and COBRA Avant-Garde (MTX+leflunomide+30 mg prednisone tapered to 5 mg from W6). Treatment modifications to target low-disease activity were mandatory from W8, if desirable and feasible according to the rheumatologist. The primary outcome was remission (28 joint disease activity score calculated with C-reactive protein <2.6) at W16 (intention-to-treat analysis). Secondary endpoints were good European League Against Rheumatism response, clinically meaningful health assessment questionnaire (HAQ) response and HAQ equal to zero. Adverse events (AEs) were registered.ResultsData from 98 Classic, 98 Slim and 94 Avant-Garde patients were analysed. At W16, remission was reached in 70.4% Classic, 73.6% Slim and 68.1% Avant-Garde patients (p=0.713). Likewise, no significant differences were shown in other secondary endpoints. However, therapy-related AEs were reported in 61.2% of Classic, in 46.9% of Slim and in 69.1% of Avant-Garde patients (p=0.006).ConclusionsFor high-risk eRA, MTX associated with a moderate step-down dose of GCs was as effective in inducing remission at W16 as DMARD combination therapies with moderate or high step-down GC doses and it showed a more favourable short-term safety profile.EudraCT number:2008-007225-39.
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16
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Kalkan A, Roback K, Hallert E, Carlsson P. Factors influencing rheumatologists' prescription of biological treatment in rheumatoid arthritis: an interview study. Implement Sci 2014; 9:153. [PMID: 25304517 PMCID: PMC4200139 DOI: 10.1186/s13012-014-0153-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/29/2014] [Indexed: 12/31/2022] Open
Abstract
Background The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists’ decisions when prescribing biological drugs. Method Semi-structured interviews, utilizing closed- and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a “parallel mixed method” approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists’ prescribing decisions, including the individual rheumatologist’s experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0153-5) contains supplementary material, which is available to authorized users.
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