title: Evaluating guidelines on continuation of anti-tumour necrosis factor treatment after 3 months: clinical effectiveness and costs of observed care and different alternative strategies.
abstract: OBJECTIVE
  To study the adherence of rheumatologists to the Dutch guidelines for anti-tumour necrosis factor alpha (TNF-alpha) treatment. The secondary objective was to evaluate alternatives to the present guidelines with regard to the percentage of responders and costs.
  
  
  METHODS
  The response (>1.2 DAS28 decrease) in patients who started on anti-TNF-alpha treatment for the first time was evaluated at 3 and 6 months after initiation. How many patients continued or discontinued their initial anti-TNF-alpha treatment was evaluated. 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 3 months 56% (N = 306) and 44% (N = 233) of all 539 evaluable patients were classified as responders or non-responders, respectively. Despite the guidelines, most (81%) (N = 189) of the non-responders continued treatment. 37% of the non-responders who continued anti-TNF-alpha treatment were eventually classified as responders at 6 months. Decision analytical modelling showed that with equal expected costs all alternative strategies would result in more responders than according to theoretical full adherence with the guidelines. "Continuation in case of partial response" had the best trade-off between successfully treated patients (64%) and unsuccessfully treated patients (17%).
  
  
  CONCLUSIONS
  There was suboptimal adherence to the Dutch guidelines for treatment with anti-TNF-alpha for rheumatoid arthritis 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, this is only recommended in patients with at least a partial response (at least 0.6 DAS28 improvement).
authors.affiliation: Department of Rheumatology, Radboud University Nijmegen Medical Centre, The Netherlands. w.kievit@reuma.umcn.nl
authors.forename: W
authors.initials: W
authors.lastname: Kievit
authors.forename: J
authors.initials: J
authors.lastname: Fransen
authors.forename: E M
authors.initials: EM
authors.lastname: Adang
authors.forename: H H
authors.initials: HH
authors.lastname: Kuper
authors.forename: T L
authors.initials: TL
authors.lastname: Jansen
authors.forename: C M A
authors.initials: CM
authors.lastname: De Gendt
authors.forename: D J R A M
authors.initials: DJ
authors.lastname: De Rooij
authors.forename: H L M
authors.initials: HL
authors.lastname: Brus
authors.forename: M A F J
authors.initials: MA
authors.lastname: van de Laar
authors.forename: P C L M
authors.initials: PC
authors.lastname: Van Riel
mesh_terms: D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000191:economics; D016527:Drug Costs; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D009010:Monte Carlo Method; D010349:Patient Compliance; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011336:Probability; D012074:Remission Induction; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha