Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists.

OBJECTIVE: To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis. METHODS: In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists. RESULTS: Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48 years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK. CONCLUSIONS: Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

Assessment of the impact of flares in ankylosing spondylitis disease activity using the Flare Illustration.

OBJECTIVES: Many AS patients report periods of perceived higher disease activity (flares). This pilot study aims to document disease activity patterns reported by AS patients and examine associations with disease-specific health status measures. METHODS: Consecutive AS patients (n = 114) were asked whether they experience flares, and if they experience symptoms of AS between flares. They were shown the Flare Illustration of disease patterns over time and asked to select the pattern that best described their disease (i) since symptom onset and (ii) in the past year. Associations between reported disease pattern and disease activity (Bath AS Disease Activity Index, BASDAI); functional impairment (Bath AS Functional Index, BASFI); AS Quality of Life (ASQoL); Back Pain (Nocturnal and Overall) and demographic features were assessed in a subsample (n = 83) (statistical significance defined at P 70% of patients) and patterns with constant symptoms since onset (vs intermittent symptoms) were associated with worse health status (ASQoL: P = 0.007; BASDAI: P = 0.029; BASFI: P = 0.013, overall back pain: P = 0.025). CONCLUSIONS: Almost all AS patients report flares in disease activity: 70-80% report constant symptoms with single/repeated flares, while 20-30% report flares with no intermittent symptoms. The former is associated with a significantly poorer health status. These findings will be validated in a prospective study.

Influence of biologic therapy on return to work in people with work disability due to ankylosing spondylitis.

OBJECTIVE: To answer the question 'does TNF blockade therapy enable people with severe AS to return to work or work more productively?'. METHODS: All patients with AS currently receiving anti-TNF therapy at two UK Hospitals were asked to complete a questionnaire. This asked about occupational history, type of work, degree of job-related physical activity, working hours and sickness absence from work both currently (on anti-TNF treatment) and pre-treatment. RESULTS: Sixty-five patients (72.3% male), aged 29-64 (mean 46.1) yrs, whose duration of anti-TNF treatment ranged from 3 to 56 (mean 19.1) months were studied. Twenty-four (36.9%) patients were receiving infliximab, 21 (32.3%) etanercept and 20 (30.8%) adalimumab. Pre-treatment, 46 (70.8%) were in employment (1 was a student); 38 (58.5%) were working full-time and 8 (12.3%) part-time; 19 (29.2%) were not working. On treatment, 50 (76.9%) patients were working, 44 (67.7%) full-time and 6 (9.2%) part-time. Two individuals who worked part-time pre-treatment had returned to work full-time. Thus, on treatment, 4 of the 19 patients who were previously unable to work returned to employment, and 2 others increased their work from part-time to full-time. Patients rated the effect of AS on work capacity as 7.05/10 pre-treatment and 2.92/10 post-treatment. Those who were working lost, on average, 15 days from work due to sick leave in the 12 months pre-treatment and 0.91 days in the first 12 months on treatment. CONCLUSIONS: Treatment of active AS with TNF blockade appears to be associated with improved capacity for work.

When is arthritis reactive?

Reactive arthritis is an important cause of lower limb oligoarthritis, mainly in young adults. It is one of the spondyloarthropathy family; it is distinguishable from other forms of inflammatory arthritis by virtue of the distribution of affected sites and the high prevalence of characteristic extra-articular lesions. Many terms have been used to refer to this and related forms of arthritis leading to some confusion. Reactive arthritis is precipitated by an infection at a distant site and genetic susceptibility is marked by possession of the HLA-B27 gene, although the mechanism remains uncertain. Diagnosis is a two stage process and requires demonstration of a temporal link with a recognised "trigger" infection. The identification and management of "sexually acquired" and "enteric" forms of reactive arthritis are considered. Putative links with HIV infection are also discussed. The clinical features, approach to investigation, diagnosis, and management of reactive arthritis are reviewed.

Poststreptococcal reactive arthritis: what is it and how do we know?

OBJECTIVE: To find out whether poststreptococcal reactive arthritis (PSRA) is a discrete, homogeneous clinical syndrome. METHOD: Literature review from case reports and case series. RESULTS: One hundred and eighty-eight cases were identified. The age distribution was bimodal, with one peak in childhood and one peak in adulthood. Eighty-three percent of streptococcal isolates were group A. The clinical presentation was heterogeneous but appeared different both from that of acute rheumatic fever (ARF) and from that of HLA B27-associated reactive arthritis. Carditis was rare. CONCLUSIONS: The term PSRA encompasses significant heterogeneity. The link between the arthritis and the streptococcal infection is unproven.

The prevalence of Mycoplasma fermentans in patients with inflammatory arthritides.

OBJECTIVES: To search for evidence that Mycoplasma fermentans is involved in the pathogenesis of some forms of human arthritis by testing for the presence of mycoplasmal DNA in joint material. METHODS: M. fermentans DNA was detected by the identification of a 104-base pair amplification product of the polymerase chain reaction (PCR). RESULTS: M. fermentans DNA was detected in synovial fluid samples from six (17%) of 35 patients with rheumatoid arthritis (RA) and 18 (21%) of 85 patients with seronegative arthritis. These detection rates were significantly greater than in samples from patients with osteoarthritis or crystal synovitis, none of 26 of these being positive. CONCLUSIONS: M. fermentans could be involved in the pathogenesis of some forms of inflammatory arthritis and this possibility is worthy of further study.

Work disability among people with ankylosing spondylitis.

OBJECTIVE: To investigate work disability among people with ankylosing spondylitis (AS) in terms of correlates and coping mechanisms. METHODS: The sample group (n = 133) was recruited through 2 sources: 1) consecutive patients attending outpatient clinics over a 6-month period, and 2) a random sample of members of the National Ankylosing Spondylitis Society. We used a cross-sectional survey with data collected by self-administered questionnaires and telephone interviews with a randomly selected subsample (n = 6). RESULTS: The majority of participants were men. The mean age was 49 years; the mean disease duration was 28 years. Thirty-one percent were unable to work because of AS, with an additional 15% reporting changes to their working lives attributable to AS (e.g., reduction in hours worked, change of job). Compared with being in full-time work, work disability was associated with being older, longer disease duration, lower educational standard, comorbidity, greater physical impairment, pain, fatigue, stiffness, anxious and depressed mood, and lower self-esteem. Descriptive data added further insight into the experience of work disability and coping with AS in a work environment. CONCLUSION: Work disability is worthy of further investigation to determine exact prevalence rates and psychosocial implications. Work disability could be addressed with simple interventions or adaptations in the workplace.