Research Confirms Importance of Individualized Treatment Choices in RA

Patients with rheumatoid arthritis (RA) value the benefits of a potential treatment over other attributes, such as adverse events or cost, suggesting that RA treatments should be individualized on a patient-by-patient basis according to study results published in the Journal of Rheumatology.

Researchers in Alberta, Canada conducted a systematic review of English-language studies of adult patients with RA to examine data on patient preferences toward treatment with disease-modifying antirheumatic drugs (DMARDs). Thirty-six studies — most rated medium- or high-quality — were included in the review.

Among discrete choice experiment studies, the investigators found that the benefits of treatment, particularly improvements in symptoms and functionality, were considered more important than potential serious and nonserious adverse events. Additionally, the route and frequency of dosing and administration were ranked more important than potential adverse events.

One study in particular found that patients were “risk-tolerant,” valuing the benefits of prednisone 15 mg over the high risk for side effects. Two studies examined health states through the lens of willingness to pay and found that patients were “willing to pay approximately 3 [times] their current monthly drug expenditure for a treatment with anti-[tumor necrosis factor] properties,” which carried “maximal improvement and [a] small risk of mild infection.”

The 3 studies that measured the willingness of patients to accept risk utilized differing approaches and resulted in different findings, including 1 study that suggested patients with established RA were “completely unwilling to accept even very rare (1/1000 or 1/100,000) risks associated with DMARD therapy for a beneficial treatment.”

Among studies that evaluated the importance of treatment outcomes, patients consistently identified pain reduction; improvement in function; and fatigue as “highly important.”

In terms of socioeconomic variables — age, education, ethnicity, and income — younger patients placed a higher level of importance on the benefits of treatment, and more educated patients were more likely to be tolerant of risk, preferring more intense treatments.

The researchers created the following 4 general statements, supported by their collected evidence:

• Treatment benefits are usually — but not always — more important than adverse events. Some studies of patients with established RA found patients to be risk-averse.

• Serious but rare adverse events, including the hypothetical risk for cancer, were usually more important than more common, but less serious, adverse events.

• Dosing regimens and monitoring requirements were generally less important than the benefits of a treatment.

• Patient preferences were variable and were frequently linked to sociodemographic characteristics.

“Taken together, these results support current intensive treatment strategies, but highlight the critical need to individualize treatment decision-making,” the researchers wrote. “The results highlight the variability in preferences between patients … For guideline developers, our review provides evidence to inform the risk/benefit trade-offs that are required when developing and grading treatment recommendations.”

Reference

Durand C, Eldoma M, Marshall DA, Bansback N, Hazlewood GS. Patient preferences for disease modifying anti-rheumatic drug treatment in rheumatoid arthritis: a systematic review [published online April 15, 2019]. J Rheumatol. doi:10.2899/jrheum.181165