COMMENTARY

Are Docs Adhering to Targeted Treatment in RA?

Bret Stetka, MD; Iris J.M. Markusse, MD

Disclosures

July 18, 2014

Medscape: What did you find?

Dr. Markusse: During the first year, protocol adherence was almost 100%, then decreased over time to ± 60% in the ninth and 10th year of follow-up, with an average over time of 79%. Rheumatologists often agreed with the study protocol (75%-90% per visit over time); often agreed with the DAS as a representative of actual disease activity (80%-90%); and were satisfied with the level of disease suppression (85%-90% over time).

Even when the rheumatologists did not agree with the study protocol or with the DAS or were dissatisfied with the level of RA suppression, they still followed the protocol in the majority of visits. Still, the risk for protocol deviation increased in these situations: The odds ratios (ORs) were 2.5 in cases of disagreement with the study protocol, 2.1 in cases of disagreement with the DAS because of underestimation, 2.0 in cases of disagreement with the DAS because of overestimation, and 1.4 in cases of dissatisfaction with the level of suppression of rheumatoid activity.

Also, in some specific conditions that could indicate a discrepancy between patients' report of pain, potentially influencing the DAS and physician's assessment of inflammation, the odds for protocol deviation were increased.

The results of this post hoc analysis show that the treat-to-target approach was indeed followed in the vast majority of patients. In addition, guidelines recommend using composite scores, such as the DAS, and our results show that the DAS performs well in estimating disease activity, according to the opinion of rheumatologists in daily practice.

Medscape: What are the clinical implications of your findings for practicing rheumatologists and other clinicians managing RA?

Dr. Markusse: Targeted treatment has proven to be effective in several clinical trials, but is not yet fully implemented in daily practice. Also, the DAS is sometimes criticized because it would be too sensitive for noninflammatory pain (visual analogue scale, tender joint count) or may be falsely elevated when the erythrocyte sedimentation rate or C-reactive protein level is high owing to nonrheumatoid inflammation. Our results show that the rheumatologists feel the DAS represents actual disease activity well in the majority of patients, and are willing to rely on it as a target in a treat-to-target approach.

We point out that our results reflect daily practice within a trial, which is a different situation from daily practice outside a trial. The trial physicians of the BeSt study visited all participating centers every 3 months to detail possible next treatment steps (depending on the DAS) in the medical record. Also, the rheumatologists were provided with the DAS, which was calculated by a study nurse, making it less time-consuming.

To conclude, these results show a great willingness among rheumatologists to adhere to a DAS-based treat-to-target protocol and specific treatment steps in the BeSt study. Therefore, we think that these results prove the feasibility of DAS-targeted treatment. We hope that our results encourage clinicians outside a trial to implement the treat-to-target approach in their daily practice.

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