Background Epidemiologic and clinical data point to the need for early and aggressive DMARD treatment of rheumatoid arthritis (RA) in order to improve functional outcome and prevent joint damage.
Objectives To identify the pharmacoeconomic, physician, and geographic variables that might modify physician choice (s) of first-line therapy for early RA.
Methods A questionnaire describing 3 RA cases with differing levels of disease severity/activity was developed. Each scenario portrayed a patient of the same age/gender, but presenting with a 6-month?s history of the signs/symptoms of mild, moderate, and severe disease activity/severity. The questionnaire was mailed to rheumatologists (adult practice) (n = 995) within four geographical regions of the United States (Northeast-NY; South-TX; Midwest-MO/NE/KS; West-CA) who were identified through the membership directory of the American College of Rheumatology. Rheumatologists were asked to identify their choice (s) of first-line therapy for each of the case profiles, first incorporating and second not incorporating cost as a factor in their treatment decision (s).
Results 375 (37.7%) questionnaires were returned between March 12 and April 25, 2000. Response rates were similar among the different geographical regions. The Table 1 demonstrates the use of NSAID/COX2 inhibitors and/or corticosteroids (CS) alone as well as the use of DMARD therapy (including anti-TNF medications) with or without NSAID/COX-2, and/or CS. Various combinations of only NSAID/COX2/CS/Hydroxychloroquine/Sulfasalazine as the initial treatment were cited by 53–56% for mild, 3–5% for moderate, and 1–2% for severe disease activity/severity. DMARD monotherapy was chosen by nearly 3/4 of all rheumatologists for the treatment of mild RA, and by 40–60% for the treatment of moderate-severe RA regardless of cost issues. For severe disease activity/severity, when cost was a consideration the use of triple DMARD therapy significantly increased. Neither geographic location nor age (as a proxy for years of training) of the rheumatologist appeared to play a role in the treatment choices.
Conclusion For the first-line therapy of early RA, medication cost played no role in the choice of mono, double, or triple therapy except in the RA scenario with severe disease activity/severity. For mild disease activity/severity: 1) a surprisingly high percent employed NSAID and/or CS alone; 2) half of the rheumatologists did not prefer MTX, gold, azathioprine, cyclosporine or any of the newer DMARDs (leflunomide, etanercept, infliximab) in this broad RA patient population. For the first-line treatment of early RA, aggressive DMARD therapy is not universally employed by all rheumatologists in the regions studied.
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