Background Although bDMARDs are effective in treating RA, they are associated with high costs and (rare) dose-dependent side effects. It is therefore desirable to find and use the lowest effective dose in individual patients. Several studies have shown that dose reduction or interval lengthening of bDMARDs using the tight control principle can be successful in RA patients while preserving stable low disease activity.1 Unfortunately, bDMARD dose optimization is still limited in clinical practice.2 The successful implementation of bDMARD dose optimization could, among other factors, be influenced by patient's attitudes and beliefs. Insight into RA patients' barriers and facilitators to bDMARD dose optimization might help to improve implementation.
Objectives To investigate the self-reported barriers and facilitators for bDMARD dose optimization in RA patients.
Methods We performed semi-structured interviews with RA patients who used or had used a bDMARD. Patients were recruited at the Sint Maartenskliniek through purposive sampling. Patients with varying characteristics were included, looking at type of bDMARD, treating rheumatologist and experience with tapering/stopping. The interviews were performed by one researcher (18 by telephone, 4 face-to-face), audio-recorded and transcribed verbatim. Two researchers analyzed the transcriptions by inductive thematic analysis using the qualitative data analysis software MAXQDA.
Results 22 RA patients were interviewed (68.2% female; age: 61.8±7.6 years; disease duration: 13.2±9.4 years; 90.9% current bDMARD user). RA patients' overall attitude towards bDMARD optimization was positive. Nine main themes emerged from the interviews: disease activity, functioning/pain, adverse effects, practical use of bDMARDs, attitude towards medication, previous experiences with tapering/stopping, social aspects, organizational aspects and costs. Within these themes, a total of 43 barriers and facilitators were identified. These include affective factors (e.g. fear), cognitive factors (e.g. beliefs) and practical factors (e.g. organization of care, costs).
Conclusions RA patients perceive several barriers and facilitators that influence their willingness to attempt tapering or stopping their bDMARD treatment. The results of this study could be used to target strategies aiming at implementation of bDMARD optimization in clinical practice.
Van Herwaarden N, van der Maas A, Minten MJ, van den Hoogen FH, Kievit W, van Vollenhoven RF et al. Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority trial. BMJ 2015; 350:h1389.
Zhang J, Xie F, Delzell E, Yun H, Lewis JD, Haynes K et al. Impact of biologic agents with and without concomitant methotrexate and at reduced doses in older rheumatoid arthritis patients. Arthritis Care Res 2015; 67(5):624–632.
Disclosure of Interest None declared
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