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Why are Dutch rheumatologists reluctant to use the COBRA treatment strategy in early rheumatoid arthritis?
  1. Lilian H.D. van Tuyl (l.vantuyl{at}
  1. VU University Medical Center, Netherlands
    1. Anne Marie C. Plass (amc.plass{at}
    1. VU University Medical Center, EMGO-institute, Netherlands
      1. Willem F. Lems (wf.lems{at}
      1. VU University Medical Center, Netherlands
        1. Alexandre E. Voskuyl (ae.voskuyl{at}
        1. VU University Medical Center, Netherlands
          1. Ben A.C. Dijkmans (bac.dijkmans{at}
          1. VU University Medical Center, Netherlands
            1. Maarten Boers (m.boers{at}
            1. VU University Medical Center, Netherlands


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

              Objective:To explore the reasons for the reluctance 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 towards prescribing the effective COBRA- therapy may be due to perceptions of complexity of the treatment schedule and negative patient-related consequences of the therapy.

              • COBRA
              • combination therapy
              • glucocorticoids
              • questionnaire
              • rheumatoid arthritis

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