Choice of second‐line disease‐modifying antirheumatic drugs after failure of methotrexate therapy for rheumatoid arthritis: A decision tree for clinical practice based on rheumatologists' preferences

Abstract

Objective. To survey rheumatologists' preferences for the choice of a second-line disease-modifying antirheumatic drug (DMARD) after inadequate response with methotrexate (MTX) therapy in rheumatoid arthritis (RA).Methods. Thirty-six rheumatologists stated their preferences for RA treatment after inadequate response with MTX therapy (optimal dose at least 6 months). From the initial scenario, we derived 54 vignettes varying by rheumatoid factor or anti-cyclic citrullinated peptide antibody presence, swollen joint count, Disease Activity Score in 28 joints, and structural damage. Respondents stated their preference among 5 therapeutic options: MTX continuation, switch to another conventional DMARD, addition of another conventional DMARD, addition of anakinra, or addition of a tumor necrosis factor (TNF) blocker. Presentation by pairs yielded 10 combinations of strategies for each variant, totaling 540 vignettes; participants evaluated a random sample of 180 vignettes. Determinants of each top-ranked option were analyzed by logistic regression. The compilation of these data served to define a therapeutic algorithm. Results. The responses of 33 rheumatologists were analyzable. Therapeutic preferences corresponded to the top-ranked options. For patients with mild or moderately active RA, either a switch or step-up strategy to another conventional DMARD was top ranked. TNF blockers were preferred for RA patients with high disease activity or progressive structural damage. On the basis of these preferences, we developed a simple decision tree for use in daily clinical practice. Conclusion. Our simple, easy-to-use decision tree developed from rheumatologists' preferences for therapy after failure of MTX therapy in RA treatment may guide rheumatologists in daily practice to choose a second-line DMARD.

Treatment strategies in rheumatoid arthritis

“…Rekomendacje francuskie, opublikowane przez Fautrel i wsp. [16], pomagają w podjęciu decyzji w przypadku niezadowalających wyników terapii z użyciem MTX. W większości przypadków zaleca się kombinację inhibitorów TNF z MTX, jednak można także rozważyć zwiększenie dawki MTX lub zamianę na innych tradycyjny LMPCh.…”

“…In a meta-analysis of 38 reports, fast MTX dose adjustment (25 mg/week initial dose, 5 mg/week dose increase monthly until 25-30 mg/week maximal dose) was more effective in reaching the treatment goals and resulted in somewhat more GI side effects than more conservative strategies (5-15 mg/week maintenance dose) [15]. A set of French recommendations published by Fautrel [16] helps in decision making in case of insufficient results of MTX therapy. In most cases, combination of TNF inhibitors with MTX is recommended; however, MTX dose increase or switch to another traditional DMARD may also be considered.…”

Management of Rheumatoid Arthritis: Consensus Recommendations From the Turkish League Against Rheumatism

“…[109] However, combining DMARDs with each other or with low-moderate dose GCs along with tight monitoring and rapid switching of treatments are also considered to be intensive treatment strategies.…”

Guidelines in rheumatology: quo vadis?

“…Fautrel et al 1 exclude cost from their analysis because in France costs to individual patients do not enter into therapeutic choices. Pharmacoeconomic issues, however, are pervasive and impact treatment decisions throughout the world.…”

“…of note, on this particular topic a paucity of good evidence is available that supports specific treatment approaches while also covering many of the important exigencies commonly encountered by clinicians. the methodologically rigorous exercise undertaken by Fautrel et al 1 raises a number of key considerations in an area of increasing notoriety in me dicine: treatment guidelines. treatment guidelines have gained increasing attention in rheumatology, largely since the availability of novel immunomodulatory therapies.…”