RESEARCH - Evaluating guildelines of continuation of anti-TNF treatment after three months

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Ann Rheum Dis. Published Online First: 14 July 2008. doi:10.1136/ard.2008.094359

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Extended Report

Evaluating guidelines of continuation of anti-TNF treatment after

three months: clinical effectiveness and costs of observed care and

different alternative strategies

W Kievit 1*, J Fransen 2, E M Adang 2, H H Kuper 3, T L Jansen 4, C MA

De Gendt 5, DJ RAM De Rooij 6, H LM Brus 7, M AFJ Van de Laar 3 and P

CLM van Riel 8

1 UMC Nijmegen, Netherlands

2 Radboud University Nijmegen Medical Centre, Netherlands

3 Medisch Spectrum Twente, Netherlands

4 Medical Centre Leeuwarden, Netherlands

5 Alysis Care Group, Netherlands

6 Sint Maartenskliniek, Netherlands

7 TweeSteden Hospital, Netherlands

8 University Medical Center Nijmegen, Netherlands

Abstract

Objective: To study the adherence of rheumatologists with the Dutch

guidelines for anti-TNF treatment. The secondary objective was to

evaluate alternatives of the present guideline with regard to the

percentage of responders and costs.

Methods: The response (> 1.2 DAS28 decrease) in patients who started

on anti-TNF for the first time was evaluated at three and six months

after start. It was evaluated how many patients continued or

discontinued their initial anti-TNF treatment. Possible alternative

guidelines were evaluated by means of a decision tree, with regard to

the expected percentage of successfully (responders) and

unsuccessfully treated patients and expected costs.

Results: At three months 56% (N=306) and 44% (N=233) of all 539

evaluable patients were classified as responder or non-responder,

respectively. Despite the guidelines, most (81%) (N=189) of the

non-responders continued treatment. Thirty-seven percent of the non

responders who continued anti-TNF were eventually classified as

responder at 6 months. Decision analytic modeling showed that with

equal expected costs all alternative strategies would result in more

responders than according to theoretical full adherence with the

guideline. 'Continuation in case of partial response' had the best

trade-off between successfully treated patients (64%) and

unsuccessfully treated patients (17%).

Conclusion: There was suboptimal adherence to the Dutch guidelines for

treatment with anti-TNF for RA patients. This seemed to be justified

by the fact that a delayed response up to 6 months was shown. If

treatment is continued despite a non-response at 3 months, we

recommend doing this only in patients with at least a partial response

(at least 0.6 DAS28 improvement).

http://ard.bmj.com/cgi/content/abstract/ard.2008.094359v1?papetoc

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