title: Influence of guideline adherence on outcome in a randomised controlled trial on the efficacy of methotrexate with folate supplementation in rheumatoid arthritis.
abstract: OBJECTIVE
  To study the influence of rheumatologists' adherence to a methotrexate guideline on efficacy and toxicity in the treatment of rheumatoid arthritis.
  
  
  METHODS
  In a 48 week randomised controlled trial of methotrexate, comparing folates with placebo, rheumatologists were advised on methotrexate dosage using a guideline reflecting daily practice. The influence of guideline non-adherence on outcome was analysed using generalised estimating equations and survival analysis.
  
  
  RESULTS
  In 51% of the 411 study patients the guidelines were always followed. Non-adherence resulted in lower doses of methotrexate in 25% of cases, and higher doses in 24%. The reduction in the disease activity score was significantly greater (mean -0.4; p = 0.0085) in the adherent group than in the "low dose" group; the "high dose" group did not differ from the adherent group. Dropout caused by severe adverse events did not differ between the three groups.
  
  
  CONCLUSIONS
  There is an indication that adherence to guidelines on methotrexate dosage may benefit patients with rheumatoid arthritis by improving disease activity without increasing toxicity. For definite proof, a randomised controlled trial comparing guideline supported dosing with usual care is needed.
authors.affiliation: Department of Rheumatology, University Medical Centre Nijmegen, PO Box 9101, 6500 HB Nijmegen, Netherlands. j.fransen@reuma.umcn.nl
authors.forename: J
authors.initials: J
authors.lastname: Fransen
authors.forename: R F J M
authors.initials: RF
authors.lastname: Laan
authors.forename: M A F J
authors.initials: MA
authors.lastname: Van Der Laar
authors.forename: T W J
authors.initials: TW
authors.lastname: Huizinga
authors.forename: P L C M
authors.initials: PL
authors.lastname: Van Riel
mesh_terms: D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D003657:Decision Making; D004311:Double-Blind Method; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D005492:Folic Acid / Q000627:therapeutic use*; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents; D005492:Folic Acid; D008727:Methotrexate