Choice of second-line disease-modifying antirheumatic drugs after failure of methotrexate therapy for rheumatoid arthritis: A decision tree for clinical practice based on rheumatologists' preferences

Authors

  • Bruno Fautrel,

    Corresponding author
    1. Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, and Université Paris VI Pierre et Marie Curie, UFR de Médecine, Paris, F-75013 France
    • Department of Rheumatology, Pitié-Salpêtrière Hospital, 83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France
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    • Dr. Fautrel has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Abbott, Wyeth, BMS, Schering-Plough, and Roche.

  • Francis Guillemin,

    1. Nancy Université, EA 4003, and INSERM, Centre Hospitalier Universitaire de Nancy, Nancy, F-54000 France
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  • Olivier Meyer,

    1. Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Bichat-Claude Bernard, Paris, F-75018 France
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  • Michel de Bandt,

    1. Centre Hospitalier d'Aulnay s\Bois, Aulnay s\Bois, F-93600 France
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    • Dr. De Bandt has received consultant fees, speaking fees, and/or honoraria (less than $10,000) from Sanofi-Aventis.

  • Jean-Marie Berthelot,

    1. Centre Hospitalo-Universitaire de Nantes, Hôtel-Dieu, Nantes, F-44000 France
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  • René-Marc Flipo,

    1. Centre Régional Hospitalo Universitaire de Lille, Lille, F-59000 France
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  • Frédéric Lioté,

    1. Hôpital Lariboisière, Paris, F-75010 France
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  • Jean-Francis Maillefert,

    1. Centre Hospitalo-Universitaire de Dijon, Université de Bourgogne, and INSERM U887, Dijon, F-21078 France
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    • Dr. Maillefert has received speaking fees (less than $10,000 each) from Abbott, BMS, Roche, and Wyeth.

  • Daniel Wendling,

    1. Centre Hospitalo-Universitaire de Besançon, Hôpital Jean Minjoz, Besançon, F-25000 France
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    • Dr. Wendling has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Abbott, BMS, Roche, and Wyeth.

  • Alain Saraux,

    1. Centre Hospitalo-Universitaire de Brest, Hôpital de la Cavale Blanche, Brest, F-29000 France
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  • Bernard Combe,

    1. Centre Hospi talo-Universitaire du Montpellier, Hôpital Lapeyronie, Montpellier, F-34000 France
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    • Dr. Combe has received consultant fees and/or speaking fees (less than $10,000 each) from Abbott, BMS, Roche, MSD, Schering, UCB, and Wyeth.

  • Xavier Le loët

    1. Centre Hospitalier Universitaire Rouen University Hospital, Rouen, F-76031 France
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    • Dr. Le Loët has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Abbott, Roche, Schering-Plough, Wyeth, and Sanofi-Aventis.


Abstract

Objective

To survey rheumatologists' preferences for the choice of a second-line disease-modifying antirheumatic drug (DMARD) after inadequate response with methotrexate (MTX) therapy in rheumatoid arthritis (RA).

Methods

Thirty-six rheumatologists stated their preferences for RA treatment after inadequate response with MTX therapy (optimal dose at least 6 months). From the initial scenario, we derived 54 vignettes varying by rheumatoid factor or anti–cyclic citrullinated peptide antibody presence, swollen joint count, Disease Activity Score in 28 joints, and structural damage. Respondents stated their preference among 5 therapeutic options: MTX continuation, switch to another conventional DMARD, addition of another conventional DMARD, addition of anakinra, or addition of a tumor necrosis factor (TNF) blocker. Presentation by pairs yielded 10 combinations of strategies for each variant, totaling 540 vignettes; participants evaluated a random sample of 180 vignettes. Determinants of each top-ranked option were analyzed by logistic regression. The compilation of these data served to define a therapeutic algorithm.

Results

The responses of 33 rheumatologists were analyzable. Therapeutic preferences corresponded to the top-ranked options. For patients with mild or moderately active RA, either a switch or step-up strategy to another conventional DMARD was top ranked. TNF blockers were preferred for RA patients with high disease activity or progressive structural damage. On the basis of these preferences, we developed a simple decision tree for use in daily clinical practice.

Conclusion

Our simple, easy-to-use decision tree developed from rheumatologists' preferences for therapy after failure of MTX therapy in RA treatment may guide rheumatologists in daily practice to choose a second-line DMARD.

Ancillary