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Evaluating guidelines of continuation of anti-TNF treatment after three months: clinical effectiveness and costs of observed care and different alternative strategies.
  1. W Kievit (w.kievit{at}
  1. UMC Nijmegen, Netherlands
    1. J Fransen (j.fransen{at}
    1. Radboud University Nijmegen Medical Centre, Netherlands
      1. E M Adang (e.adang{at}
      1. Radboud University Nijmegen Medical Centre, Netherlands
        1. H H Kuper (h.kuper{at}
        1. Medisch Spectrum Twente, Netherlands
          1. T L Jansen (t.jansen{at}
          1. Medical Centre Leeuwarden, Netherlands
            1. C MA De Gendt (cdegendt{at}
            1. Alysis Care Group, Netherlands
              1. DJ RAM De Rooij (dj.derooij{at}
              1. Sint Maartenskliniek, Netherlands
                1. H LM Brus (hbrus{at}
                1. TweeSteden Hospital, Netherlands
                  1. M AFJ Van de Laar (m.vandelaar{at}
                  1. Medisch Spectrum Twente, Netherlands
                    1. P CLM van Riel (p.vanriel{at}
                    1. University Medical Center Nijmegen, Netherlands


                      Objective: To study the adherence of rheumatologists with the Dutch guidelines for anti-TNFα treatment. The secondary objective was to evaluate alternatives of the present guideline with regard to the percentage of responders and costs.

                      Methods: The response (> 1.2 DAS28 decrease) in patients who started on anti-TNFα for the first time was evaluated at three and six months after start. It was evaluated how many patients continued or discontinued their initial anti-TNFα treatment. Possible alternative guidelines were evaluated by means of a decision tree, with regard to the expected percentage of successfully (responders) and unsuccessfully treated patients and expected costs.

                      Results: At three months 56% (N=306) and 44% (N=233) of all 539 evaluable patients were classified as responder or non-responder, respectively. Despite the guidelines, most (81%) (N=189) of the non-responders continued treatment. Thirty-seven percent of the non responders who continued anti-TNFα were eventually classified as responder at 6 months. Decision analytic modeling showed that with equal expected costs all alternative strategies would result in more responders than according to theoretical full adherence with the guideline. ‘Continuation in case of partial response’ had the best trade-off between successfully treated patients (64%) and unsuccessfully treated patients (17%).

                      Conclusion: There was suboptimal adherence to the Dutch guidelines for treatment with anti-TNFα for RA patients. This seemed to be justified by the fact that a delayed response up to 6 months was shown. If treatment is continued despite a non-response at 3 months, we recommend doing this only in patients with at least a partial response (at least 0.6 DAS28 improvement).

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