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Objective. To describe Canadian clinical practice patterns in the pharmacological management of rheumatoid arthritis (RA) and identify practice variations.
Methods. A 44-item pre-guideline needs assessment survey was sent to all members of the Canadian Rheumatology Association (CRA). Descriptive statistics were used to summarize respondent characteristics and practice patterns.
Results. Survey respondents (n = 164) reported variations in practice regarding assessment strategies, treatment with disease-modifying antirheumatic drug monotherapy versus combination therapy, methotrexate dosing and escalation, corticosteroid strategies, and optimal use of biologics.
Conclusions. Practice variations identified in this pre-guideline needs assessment survey were used to formulate key treatment questions for the development of CRA recommendations.
The last decade has brought significant changes in the management of rheumatoid arthritis (RA) that have improved the prognosis for many adults living with RA1,2. For patients this means symptom control, performing activities of daily living, remaining in the workforce, and improving overall quality of life3. Rheumatology healthcare professionals, however, are faced with the challenge of keeping up with the large volume of research studies pertaining to common as well as new therapeutic agents that continue to emerge to treat RA. High quality clinical practice guidelines can be useful for synthesizing and transmitting evidence-based healthcare to appropriate knowledge users4. However, practice recommendations regarding the pharmacological management of RA developed for the Canadian cultural and organizational healthcare context are lacking5.
The objectives of this pre-guideline needs assessment survey were to: (1) describe current practice patterns regarding the pharmacological management of RA in a sample of Canadian rheumatology professionals; and (2) identify practice variations to formulate potential key treatment questions for the development of clinical practice recommendations.
MATERIALS AND METHODS
A questionnaire including demographic/practice characteristics, general treatment questions, and clinical case scenarios related to RA assessment strategies and treatment with corticosteroids and traditional and biologic disease-modifying antirheumatic drugs (DMARD) was developed by the Canadian Rheumatology Association (CRA) Therapeutics Committee, pilot tested with 12 rheumatologists and fellows, and refined to 44 items. In the summer of 2007, the questionnaire was sent to all members of the CRA anonymously, a convenience sample of rheumatology healthcare professionals across Canada. Data were collected using Survey Monkey (www.survey-monkey.com) and exported to Excel for descriptive analysis. The CRA Therapeutics Committee reviewed results of each survey question at a face-to-face meeting and identified practice variations for the purpose of formulating key treatment questions to be addressed through the development of clinical practice recommendations.
One hundred sixty-four members of the CRA completed the questionnaire. Sixty-two percent were male and 60% had been in practice for 10+ years. The greatest proportion of respondents resided in Ontario (43%) followed by the western provinces (British Columbia, Alberta, Saskatchewan, Manitoba; 30%), Quebec (19%), and the eastern provinces (New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland; 8%). Just over half of respondents (51%) reported practicing in academic or teaching hospitals and 73% reported that at least one-quarter of their patients were seen for RA.
Initial DMARD treatment strategies for patients with moderate to severe RA were about evenly split between methotrexate (MTX) monotherapy (up to 20–25 mg per week) and MTX combination therapy. Frequency of radiographs varied from every 6 to 12 months, with annual radiographs most commonly reported (49%), and 12%–14% of respondents were unsure if they would obtain magnetic resonance imaging/or ultrasound in new patients with normal radiographs. The most common use of corticosteroids was as temporary bridge therapy (63%), with intramuscular or intraarticular (44%) and oral prednisone 5–10 mg or 10 mg (46%) as the most commonly reported treatment strategies. Most starting doses for MTX ranged from 10 mg to 20 mg per week, with 15 mg most commonly reported (51%), and 25 mg was the most common maximum dose (84%), with only 1% that reported using > 30 mg. Timing for escalation mostly varied between 4 and 12 weeks, with 10–12 weeks most commonly reported (25%). Fifty-six percent used subcutaneous MTX frequently, and only 1% reported never using it (Table 1).
Patterns for initiating biologic therapy varied greatly. Provided that there was unrestricted access, 57% reported that they would start tumor necrosis factor inhibitor (anti-TNF) after 3–6 months of combination therapy [MTX + leflunomide (LEF) = 14%; MTX + hydroxychloroquine (HCQ) + sulfasalazine (SSZ) = 33%], 31% after 3–6 months on MTX monotherapy 20–25 mg per week, and 16% immediately in patients with moderate to severe RA. After failure of 1 anti-TNF, 68% reported they would switch to a second anti-TNF, and 32% reported they would switch to another mechanism of action [MTX + abatacept (ABAT) = 21%; MTX + rituximab (RTX) = 16%]. There were multiple reasons for switching biologics, with swollen joint count > 5 (70%) and radiographic progression (45%) most commonly reported (Table 1).
The most common safety issues that patients were warned about prior to starting all biologics were pneumonia or serious infections (98%), tuberculosis (96%), injection site reactions (90%), and malignancy (82%). Two-thirds of respondents reported that it was important to ensure vaccines were up to date prior to treatment with anti-TNF or abatacept and 82% prior to RTX. Roughly 50% reported that they would stop MTX prior to surgery, while 90% reported that they would stop biologics (except RTX), with great variability in the timing for suspension. Forty percent believed that treatment with anti-TNF therapy was associated with an increased risk of lymphoma over and above the risk attributable to RA, and 25% and 11% reported that anti-TNF or ABAT and RTX, respectively, were associated with an increased risk of solid tumors.
Through this pre-guideline needs assessment survey of 164 Canadian rheumatology healthcare professionals, practice variations were observed regarding RA assessment strategies; treatment with DMARD monotherapy versus combination therapy; MTX dosing and escalation, appropriate corticosteroid strategies, defining treatment responses; and optimal use of biologics (when to start, when to change, what to change to, safety and monitoring).
Our study had certain limitations. The needs assessment survey may have failed to identify all practice strategies considered by Canadian rheumatology professionals. However, survey questions were pilot-tested with a panel of rheumatology experts and trainees, and included multiple response options and an open-ended “other” category in an effort to increase response sensitivity. Second, our study was based on a convenience sample of members of the CRA who responded to the needs assessment survey. Although respondents may not be representative of the opinions of all Canadian rheumatology professionals, demographic distributions were similar to those of the 2007 CRA membership as a whole (n = 445) with respect to gender (male = 61% vs 60%), province (western provinces = 29% vs 30%, Ontario = 41% vs 43%, Quebec = 21% vs 19%, eastern provinces = 9% vs 8%), and practice setting (academic/teaching hospitals = 59% vs 51%). Last, we cannot rule out the possibility that individual practice strategies may have changed since 2007; however, notable system changes are limited to the very recent approval in Canada of 2 new anti-TNF agents and an interleukin 6 inhibitor with indications similar to those of other biologic agents.
In conclusion, practice variations identified in this pre-guideline needs assessment survey were used to formulate key treatment questions for the development of 2011 CRA recommendations for the pharmacologic management of RA6,7.
Development of the survey was supported by funds from the Canadian Rheumatology Association. O. Schieir is supported by a Fonds de la Recherche en Santé de Québec (FRSQ) Doctoral Research Award. Dr. Akhavan is supported by a UCB/CRA/TAS Post-Graduate Rheumatology Fellowship. Dr. Hazlewood is supported by a UCB/CRA/TAS Post-Graduate Rheumatology Fellowship and an Alberta Heritage Foundation for Medical Research Clinical Fellowship. Dr. Bombardier holds a Pfizer Chair and a Canada Research Chair in Knowledge Transfer for Musculoskeletal Care.
- Accepted for publication June 28, 2011.