Prescribing trends in disease modifying antirheumatic drugs for RA

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Prescribing trends in disease modifying antirheumatic drugs for

rheumatoid arthritis: a survey of practicing Canadian rheumatologists.

Pope JE, Hong P, Koehler BE.

Department of Medicine, University of Western Ontario, London, Canada.

OBJECTIVE: To determine the prescribing and monitoring practices of

disease modifying antirheumatic drugs (DMARD) for Canadian

rheumatologists in their treatment of rheumatoid arthritis (RA).

METHODS: A survey questionnaire was mailed to 279 rheumatologists with a

70% response rate after 2 mailings. RESULTS: Antimalarials are

prescribed commonly, with the preference being hydroxychloroquine (HCQ).

For antimalarials, 78% do not routinely monitor laboratory results.

There was wide variability in monitoring for ocular complications.

Thirty-eight percent of rheumatologists never do a baseline eye

examination and 39% always do. All rheumatologists frequently use

methotrexate (MTX) in RA. The reported mean maximum dose for MTX was

25.1 mg/week (range 7.5-50), with 86% routinely using folate.

Ninety-eight percent prescribe sulfasalazine (SSZ) for RA. Mean maximum

dose prescribed for SSZ was 2.8 g/day. Most never used oral gold, while

IM gold was used by 95%. Only 9% frequently use azathioprine in RA, to a

mean maximum dose of 185 mg/day. Less commonly prescribed DMARD included

cyclosporine (66% frequently; 25% never) and D-penicillamine (2%

frequently; 53% never). There was a wide range of what exactly was

monitored with respect to laboratory tests, and at what frequency, for

many of the DMARD. Nearly all (99%) used combination DMARD, the most

popular combination being MTX-HCQ. There were some significant

differences in treatment trends when comparing year of fellowship

completion, but no sex or type of practice differences were found. Those

completing fellowships prior to 1984 were more likely to prescribe

azathioprine (p < 0.03), chloroquine (p < 0.01) and chronic steroids (p

< 0.1) in RA. There was, however, regional variability in the use of IM

gold and newer DMARD--they were most prescribed in Western Canada and

least in Quebec. Cyclosporine was prescribed most frequently in Quebec

compared to Western Canada and least in Ontario and the Atlantic

Provinces. CONCLUSION: Canadian rheumatologists are fairly similar in

their use of common DMARD and combination therapies in RA. There is

variability in the use of some older medications including azathioprine

and chloroquine, depending on when rheumatology training was completed,

and use of some drugs varies by region.