Clinical practice format for choosing a second-line disease modifying anti-rheumatic drug in early rheumatoid arthritis after failure of 6 months' first-line DMARD therapy.
BACKGROUND
The objective was to develop a clinical practice format for choosing a second-line disease-modifying anti-rheumatic drug (DMARD) after a 6-month course of a first-line DMARD in patients with early RA.


METHODS
A panel of 34 experts selected treatment option from various scenarios using the Thurstone pairwise method. The experts had to choose between two proposed DMARDs without proposing other options. The scenarios were obtained using the three items: DAS28, rheumatoid factor status and radiographic structural damage. A sample of 240 among 480 scenarios for each expert was taken at random. Responses given by at least 20% of the experts were considered pertinent.


RESULTS
Recommendations for choosing a second DMARD for early RA after failure of a 6-month course of a first-line DMARD were established according to 4 parameters: type of first-line DMARD, activity, RF status and radiographic joint damage. The results of this study suggest that in patients with early RA who fail a 6-month course of first-line DMARD therapy, the best options may be addition of corticosteroid when disease activity is moderate to high and switching to a biologic agent when further radiographic joint damage occurs, particularly in patients with positive tests for RF.


CONCLUSIONS
Although our scenarios did not include step-up (add instead of substitute) strategies, except for corticosteroids, we feel that the format presented here can optimise the management of patients with early RA seen in clinical practice.
Meyer
Olivier
O
Department of Rheumatology, AP-HP, Bichat Paris 7 University Hospital, CHU Bichat, 46 rue Henri Huchard, 75018 Paris, France. olivier.meyer@bch.aphp.fr
de Bandt
Michel
M
Berthelot
Jean-Marie
JM
Cantagrel
Alain
A
Combe
Bernard
B
Fautrel
Bruno
B
Flipo
René-Marc
RM
Lioté
Frédéric
F
Maillefert
Jean-Francis
JF
Saraux
Alain
A
Wendling
Daniel
D
Guillemin
Francis
F
Le Loët
Xavier
X
D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000378:metabolism; D015415:Biomarkers / Q000378:metabolism; D003661:Decision Support Techniques; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D000068800:Etanercept; D006801:Humans; D007074:Immunoglobulin G / Q000627:therapeutic use; D007555:Isoxazoles / Q000627:therapeutic use; D000077339:Leflunomide; D008727:Methotrexate / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D011859:Radiography; D018124:Receptors, Tumor Necrosis Factor / Q000627:therapeutic use; D012217:Rheumatoid Factor / Q000378:metabolism; D012460:Sulfasalazine / Q000627:therapeutic use; D017211:Treatment Failure
D018501:Antirheumatic Agents; D015415:Biomarkers; D007074:Immunoglobulin G; D007555:Isoxazoles; D018124:Receptors, Tumor Necrosis Factor; D012460:Sulfasalazine; D012217:Rheumatoid Factor; D000077339:Leflunomide; D000068800:Etanercept; D008727:Methotrexate