title: 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.
abstract: 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.
authors.affiliation: Department of Rheumatology, AP-HP, Bichat Paris 7 University Hospital, CHU Bichat, 46 rue Henri Huchard, 75018 Paris, France. olivier.meyer@bch.aphp.fr
authors.forename: Olivier
authors.initials: O
authors.lastname: Meyer
authors.forename: Michel
authors.initials: M
authors.lastname: de Bandt
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Berthelot
authors.forename: Alain
authors.initials: A
authors.lastname: Cantagrel
authors.forename: Bernard
authors.initials: B
authors.lastname: Combe
authors.forename: Bruno
authors.initials: B
authors.lastname: Fautrel
authors.forename: René-Marc
authors.initials: RM
authors.lastname: Flipo
authors.forename: Frédéric
authors.initials: F
authors.lastname: Lioté
authors.forename: Jean-Francis
authors.initials: JF
authors.lastname: Maillefert
authors.forename: Alain
authors.initials: A
authors.lastname: Saraux
authors.forename: Daniel
authors.initials: D
authors.lastname: Wendling
authors.forename: Francis
authors.initials: F
authors.lastname: Guillemin
authors.forename: Xavier
authors.initials: X
authors.lastname: Le Loët
mesh_terms: 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
chemical_list: 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