Patient Preferences for Treatment of Rheumatoid Arthritis

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Patient Preferences for Treatment of Rheumatoid Arthritis

A DGReview of : " Patient Preferences for Treatment of Rheumatoid Arthritis "

ls of the Rheumatic Diseases (ARD Online)

04/01/2004

By Kathleen A. Wildasin, MA

Older patients prefer etanercept over methotrexate, gold, and leflunomide

for the treatment of rheumatoid arthritis (RA) because of risk aversion for

drug toxicity, investigators of a recent study say.

To assess patient preferences for the treatment of RA, Liana Fraenkel, MD,

Yale University, New Haven, Connecticut, United States, and colleagues

interviewed 120 individuals (mean age, 70 ± 12 years; 76% female) who were

receiving treatment at 3 rheumatology practices serving the New Haven

community. Sixty percent of participants were receiving a disease-modifying

antirheumatic drug (DMARD) and 64% of patients described their

arthritis-related health status as " poor " or " very poor. " Mean duration of

RA in the group was 8 ± 5 years.

The investigators first obtained patient " values " (measured in utility

units) for 16 DMARD characteristics, including effectiveness (i.e., expected

benefits), risk of adverse events, and cost, from previously published

studies. Analysing the relative differences in utilities can help to explain

treatment preferences -- for example, the value that an individual places on

eliminating risk of adverse events versus maximizing improvement of specific

benefits can be compared in terms of the number of utility units assigned to

each.

The investigators then elicited preferences from study participants by

asking them to weigh the risks and benefits of specific treatment

characteristics, and utilities were calculated based on answers to

" trade-off " questions using the interactive computer program Adaptive

Conjoint Analysis (ACA). Simulations to derive preferences that represented

etanercept, methotrexate, gold, and leflunomide under various " risk-benefit

scenarios " were executed by the investigators.

Sixty-nine percent of patients were familiar with methotrexate, 20% of

patients with leflunomide, 18% with gold, and 8% with etanercept and/or

infliximab as RA treatment options.

Based on individual expressed preferences and the characteristics of current

treatments, the investigators were able to identify " the option that best

fit each patient's perspective. "

Results of the study showed that when presented with the " base-case "

scenario -- that is, the maximum benefit reported in the literature, low

risk of side effects, and low equal monthly co-pays -- 95% of study

participants chose etanercept over methotrexate, gold, and leflunomide. When

all 4 drugs were portrayed as " equally effective, " 88% of participants still

preferred etanercept because of its " safer short-term adverse effect

profile, " and 80% of participants favoured etanercept even if the co-pay was

increased.

" [W]e found that many older patients with RA prefer a DMARD with fewer

established adverse effects and an unknown long-term safety profile over

better established drugs with a greater number of common, albeit reversible

adverse effects, and well-known long-term risk profiles, " the investigators

wrote.

Although the investigators cautioned that the results of the study should

not be viewed as " prescriptive, " they also pointed out that " eliciting and

incorporating " patient preferences is an important part of the RA treatment

decision-making process.