Drug-free holiday in patients with rheumatoid arthritis: a qualitative study to explore patients’ opinion

Markusse, I.M.; Akdemir, G.; Huizinga, T.W.J.; Allaart, Cornelia F

doi:10.1007/s10067-014-2500-y

Cited by 14 publications

(11 citation statements)

References 14 publications

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“…Three qualitative studies into the patient perspective on bDMARD dose reduction were identified [98–100]. These studies all found that dose reduction is associated with both positive and negative perceived aspects for patients.…”

Section: Resultsmentioning

confidence: 99%

bDMARD Dose Reduction in Rheumatoid Arthritis: A Narrative Review with Systematic Literature Search

Verhoef

Tweehuysen

Hulscher³

et al. 2017

Rheumatol Ther

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IntroductionAlthough bDMARDs are effective in the treatment of RA, they are associated with dose-dependent side effects, patient burden, and high costs. Recently, many studies have investigated the possibility of discontinuing or tapering bDMARDs when patients have reached their treatment goal. The aim of this review is to provide a narrative overview of the existing evidence on bDMARD dose reduction and to provide answers to specific dose-reduction-related questions that are of interest to clinicians.MethodsWe systematically searched for relevant studies in four scientific databases. Furthermore, we screened the references of reviews and relevant studies.ResultsOur searches resulted in 45 original studies of bDMARD dose reduction in RA patients (15 RCTs and 30 observational studies). Current evidence shows that bDMARD dose reduction can be considered in all RA patients who achieve stable (e.g., ≥6 months) low disease activity or remission. The best strategies seem to be disease-activity-guided dose optimization and fixed dose reduction, since direct bDMARD discontinuation (without restarting) results in a high flare rate, worse physical functioning, and more joint damage. When tapering the bDMARD treatment of a patient, disease activity should be monitored closely, and if a flare occurs, the dose should be increased to the lowest effective dose. Current evidence shows that restarting bDMARD treatment is effective and safe. Unfortunately, no clear predictors of successful dose reduction have been identified so far.ConclusionThe current evidence and rising healthcare costs urge that dose reduction should be considered for eligible patients. However, the decision to start dose reduction should be made in shared decision-making. Future research should focus not only on a better understanding of the effects of dose reduction on clinical outcomes but also on the perspectives of patients and physicians as well as the implementation of this new treatment principle.Electronic supplementary materialThe online version of this article (doi:10.1007/s40744-017-0055-5) contains supplementary material, which is available to authorized users.

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Section: Resultsmentioning

confidence: 99%

bDMARD Dose Reduction in Rheumatoid Arthritis: A Narrative Review with Systematic Literature Search

Verhoef

Tweehuysen

Hulscher³

et al. 2017

Rheumatol Ther

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“…In addition, an immediate withdrawal of bDMARDs would be unlikely to gain acceptance due to risk aversion among patients and rheumatologists. Patients with RA have been found to be reluctant to change their treatment (e.g., to try a new drug, modify the dose of an existing treatment, or take a so-called drug holiday) and have expressed fears of losing disease control or experiencing flares and side effects [54].…”

Section: Discussionmentioning

confidence: 99%

Cost-utility analysis of de-escalating biological disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis

2020

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Objective Recent guideline updates have suggested de-escalating DMARDs when patients with rheumatoid arthritis achieve remission or low disease activity. We aim to evaluate whether it is cost-effective to de-escalate the biological form of DMARDs (bDMARDs). Methods Using a Markov model, we performed a cost-utility analysis for RA patients on bDMARD treatment. We compared continuing treatment (standard care) to a tapering approach (i.e., an immediate 50% dose reduction), withdrawal (i.e., an immediate 100% dose reduction) and tapering followed by withdrawal of bDMARDs. The parametrization is based on a comprehensive literature review. Results were computed for 30 years with a cycle length of three months. We applied the payer's perspective for Germany and conducted deterministic and probabilistic sensitivity analyses. Results Tapering or withdrawing bDMARD treatment resulted in ICERs of €526,254 (incr. costs-78,845, incr. QALYs-0.1498) or €216,879 (incr. costs-€121,691, incr. QALYs-0.5611) compared to standard care. Tapering followed by withdrawal resulted in a loss of 0.4354 QALYs and savings of €107,969 per patient, with an ICER of €247,987. Deterministic sensitivity analysis revealed that our results remained largely unaffected by parameter changes. Probabilistic sensitivity analysis suggests that tapering, withdrawal and tapering followed by withdrawal were dominant in 39.8%, 28.2% and 29.0% of 10,000 iterations. Conclusion Our findings suggest that de-escalating bDMARDs in patients with RA may result in high cost savings but also a decrease in quality of life compared to standard care. If decision

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“…Obviously, daily practice outside a trial often presents a different situation. It is known that outside a trial patients may be reluctant to treatment adjustments , and the same may be true for rheumatologists.…”

Section: Discussionmentioning

confidence: 99%

Evaluating Adherence to a Treat‐to‐Target Protocol in Recent‐Onset Rheumatoid Arthritis: Reasons for Compliance and Hesitation

Markusse

Dirven

Han

et al. 2016

Arthritis Care & Research

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Objective. To evaluate rheumatologists' adherence to a low Disease Activity Score (DAS)-steered treat-to-target (T2T) strategy in treatment of patients with rheumatoid arthritis (RA) and to assess associated conditions. Methods. Data of the BeSt study were used, a multicenter T2T strategy trial with 10-year followup. During 3 monthly visits, the physician answered questions about satisfaction with level of RA suppression, agreement with the study protocol, and agreement with the DAS. Associations between the answers and nonadherence were evaluated. Results. Protocol adherence decreased over time from 100% to 60% per visit, with an average over time of 79%. Rheumatologists mostly agreed with the DAS (80-90% of visits over time) and were satisfied with the treatment steps (75-90%) and with the level of RA suppression (85-90%). The odds for protocol violation were higher when the rheumatologist disagreed with the DAS (odds ratio [OR] 2.3, 95% confidence interval [95% CI] 2.0-2.7 when they thought the DAS overestimated actual disease activity; OR 2.5, 95% CI 2.0-3.1 when they thought the DAS underestimated actual disease activity) or with the next required treatment step (OR 3.0, 95% CI 2.5-3.5), and when the physician was dissatisfied with disease suppression (OR 1.3, 95% CI 1.1-1.6). Conclusion. Rheumatologists generally agreed with and followed a 10-year followup DAS-steered T2T strategy. Disagreement with the DAS or the required treatment and dissatisfaction with the level of disease suppression were risk factors for nonadherence. These results indicate the feasibility of continued protocol-driven T2T therapy. For daily practice, adherence to T2T therapy might be improved by adopting the structure components of a clinical trial.

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Drug-free holiday in patients with rheumatoid arthritis: a qualitative study to explore patients’ opinion

Cited by 14 publications

References 14 publications

bDMARD Dose Reduction in Rheumatoid Arthritis: A Narrative Review with Systematic Literature Search

bDMARD Dose Reduction in Rheumatoid Arthritis: A Narrative Review with Systematic Literature Search

Cost-utility analysis of de-escalating biological disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis

Evaluating Adherence to a Treat‐to‐Target Protocol in Recent‐Onset Rheumatoid Arthritis: Reasons for Compliance and Hesitation

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