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Why are Dutch rheumatologists reluctant to use the COBRA treatment strategy in early rheumatoid arthritis?
  1. Lilian H D van Tuyl1,
  2. Anne Marie C Plass2,
  3. Willem F Lems3,
  4. Alexandre E Voskuyl3,
  5. Ben A C Dijkmans3,
  6. Maarten Boers1
  1. 1Department of Clinical Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
  2. 2EMGO Institute, VU University Medical Center, Amsterdam, The Netherlands
  3. 3Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
  1. Correspondence to:
    Ir L H D van Tuyl
    Department of Clinical Epidemiology & Biostatistics, VU University Medical Center, PO Box 7057, 1053 MB Amsterdam, The Netherlands; L.vantuyl{at}


Background: The Combinatietherapie Bij Reumatoide Artritis (COBRA) trial has proved that combination therapy with prednisolone, methotrexate and sulphasalazine is superior to sulphasalazine monotherapy in suppressing disease activity and radiological progression of early rheumatoid arthritis (RA). In addition, 5 years of follow-up proved that COBRA therapy results in sustained reduction of the rate of radiological progression. Despite this evidence, Dutch rheumatologists seem reluctant to prescribe COBRA therapy.

Objective: To explore the reasons for the reluctance in Dutch rheumatologists to prescribe COBRA therapy.

Methods: A short structured questionnaire based on social–psychological theories of behaviour was sent to all Dutch rheumatologists (n = 230).

Results: The response rate was 50%. COBRA therapy was perceived as both effective and safe, but complex to administer. Furthermore, rheumatologists expressed their concern about the large number of pills that had to be taken, the side effects of high-dose prednisolone and the low dose of methotrexate. Although the average attitude towards the COBRA therapy was slightly positive (above the neutral point), the majority of responding rheumatologists had a negative intention (below the neutral point) to prescribe COBRA therapy in the near future.

Conclusion: The reluctance of Dutch rheumatologists to prescribe effective COBRA therapy may be due to perceptions of complexity of the treatment schedule and negative patient-related consequences of the therapy.

  • COBRA, Combinatietherapie Bij Reumatoide Artritis
  • MTX, methotrexate
  • RA, rheumatoid arthritis
  • SSZ, sulphasalazine

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  • Competing interests: None declared.

  • Published Online First 28 March 2007