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Patient Preferences for Treatment of Rheumatoid Arthritis

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.





Ann Rheum Dis 2004 Mar 5;[Epub ahead of print]. "Patient Preferences for Treatment of Rheumatoid Arthritis"

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