Herman L. M. Brus

Implementation of a Treat-to-Target Strategy in Very Early Rheumatoid Arthritis Results of the Dutch Rheumatoid Arthritis Monitoring Remission Induction Cohort Study

OBJECTIVE Clinical remission is the ultimate therapeutic goal in rheumatoid arthritis (RA). Although clinical trials have proven this to be a realistic goal, the concept of targeting at remission has not yet been implemented. The objective of this study was to develop, implement, and evaluate a treat-to-target strategy aimed at achieving remission in very early RA in daily clinical practice. METHODS Five hundred thirty-four patients with a clinical diagnosis of very early RA were included in the Dutch Rheumatoid Arthritis Monitoring remission induction cohort study. Treatment adjustments were based on the Disease Activity Score in 28 joints (DAS28), aiming at a DAS28 of <2.6 (methotrexate, followed by the addition of sulfasalazine, and exchange of sulfasalazine with biologic agents in case of persistent disease activity). The primary outcome was disease activity after 6 months and 12 months of followup, according to the DAS28, the European League Against Rheumatism (EULAR) response criteria, and the modified American College of Rheumatology (ACR) remission criteria. Secondary outcomes were time to first DAS28 remission and outcome of radiography. RESULTS Six-month and 12-month followup data were available for 491 and 389 patients, respectively. At 6 months, 47.0% of patients achieved DAS28 remission, 57.6% had a good EULAR response, and 32.0% satisfied the ACR remission criteria. At 12 months, 58.1% of patients achieved DAS28 remission, 67.9% had a good EULAR response, and 46.4% achieved ACR remission. The median time to first remission was 25.3 weeks (interquartile range 13.0-52.0). The majority of patients did not have clinically relevant radiographic progression after 1 year. CONCLUSION The successful implementation of this treat-to-target strategy aiming at remission demonstrated that achieving remission in daily clinical practice is a realistic goal.

Determinants of compliance with medication in patients with rheumatoid arthritis: the importance of self-efficacy expectations

UNLABELLED In this study we examine which factors are related to compliance with medication in patients suffering from rheumatoid arthritis (RA). PATIENTS persons suffering recently developed, active RA, who cooperated in a randomized study on the effect of patient education. We analyzed the relation between adherence to Sulphasalazine therapy and personal factors, environmental influences, demographic factors, disease-related factors, and barriers to compliance. Moreover, a logistical regression analysis was performed on these factors, considering > or = 80% a high compliance, both with compliance as dependent factor. Only self-efficacy correlated with compliance (r = 0.58; P < 0.001). The logistical regression analysis identified self-efficacy as the only factor determining > or = 80% adherence (P = 0.01). Self-efficacy regarding the use of prescribed medication is related to compliance with this treatment. Further study is needed to determine the test characteristics of self-efficacy as a predictor for compliance with medication.

Compliance in Rheumatoid Arthritis and the Role of Formal Patient Education

OBJECTIVE This study was performed to determine the compliance with the basic treatments for rheumatoid arthritis (RA; medication, physical therapy, and ergonomic measures), to study psychological factors that influence compliance in light of the social learning theory, to learn whether patient education positively influences compliance and health, and to find an approach to patient education that improves compliance. METHODS A MEDLINE search of the English language literature was performed. RESULTS Few studies have dealt with compliance in RA patients; levels of adherence are generally low. According to the social learning theory, human function involves a continuous interaction between behavior, personal factors, and external environment. Self-efficacy is a personal factor that refers to the belief in ones capabilities and opportunities for being compliant with treatment advice. Patient education may improve ergonomic performance and compliance with physical exercise programs. CONCLUSIONS Compliance with medication was infrequently studied. Whether improved compliance leads to better health status could not be determined. Compliance with RA treatments are generally low. Systematic study of the effect of patient education on treatment and health is warranted. Self-efficacy enhancing techniques in patient education may improve compliance.

Tapering and discontinuation of methotrexate in patients with RA treated with TNF inhibitors: data from the DREAM registry.

Objectives To study the number of patients that taper or discontinue concomitant methotrexate (MTX) in daily practice in patients with rheumatoid arthritis (RA) treated with tumour necrosis factor inhibitor (TNFi) and to analyse the effects of that adaption on disease activity and drug survival. Methods Data were collected from the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry. Patients who started their first TNFi were included in the study. Treatment effectiveness after MTX tapering or discontinuation was analysed using Disease Activity Score of 28 joints (DAS28). Drug survival of the TNFi was analysed using the Cox proportional hazard model with a time-dependent covariate. Results In 458 patients (34%), MTX was tapered, 126 patients (10%) discontinued MTX and 747 patients (56%) continued MTX at the same dose. On average, DAS28 improved after tapering MTX (−0.40, −0.45) and after stopping MTX (−0.28, −0.12) at 6 and 12 months. In the taper group, 21% of the patients relapsed (DAS28 increase >0.6), and in the discontinuation group this was 21% and 24% at 6 and 12 months, respectively. Patients who taper and discontinue MTX have a similar DAS28 score over time as patients who continue MTX. Moreover, there was no influence of tapering or discontinuation of MTX on long-term drug survival of TNFi. Conclusions In daily practice, tapering or discontinuation of concomitant MTX in patients with RA treated with TNFi frequently occurs and it does not seem to influence the average DAS28 over time or the long-term TNFi drug survival. It appears that in daily clinical practice the correct patients are selected to taper or discontinue MTX.

Development of a Brief Observation Method for Measuring Joint Protective Behaviors: Reliability

Ergonomic measures (joint protection, energy conservation and the use of devices) are part of basic treatment in rheumatoid arthritis (RA). It is of increasing importance that Health Care is based on evidence. Therefore, attention should be paid to the assessment of ergonomic performance in clinical practice and in studies on the effects of formal patient education. We describe a first step in developing a practical test for joint protection performance. The inter- and intraobserver reliability of this test was high in a preliminary study among 15 RA patients. The presented test is reliable and easy to perform. There is a need to determine the validity of the test.