In the Literature - December 2017

VBCR - December 2017, Vol 6, No 5 - In the Literature

Patient Preference Outweighs Efficacy for Rheumatologists Choosing Therapy for Moderate Disease Activity

In countries that considerably restrict the prescribing of costly rheumatoid arthritis medications, rheumatologists are willing to focus less on treatment efficacy to accommodate patient preference in individuals with moderate versus high disease activity, according to the results of a recent study (Hifinger M, et al. RMD Open. 2017;3:e000453).

Seeking to evaluate the influence that disease activity has on treatment choices made by rheumatologists in countries that restrict patient access to expensive drugs, the researchers surveyed 148 rheumatologists from Hungary, Romania, and the United Kingdom using 2 discrete choice experiments that involved choosing between 2 treatments for patients with high or moderate disease activity between October 2014 and May 2015. The treatment options were unlabeled and varied in terms of efficacy, safety, patient preference, total cost, and cost-effectiveness.

Although efficacy played a bigger role than patient preference and the safety and economic aspects of therapy when it came to treatment selection in patients with high or moderate disease activity, the importance of drug efficacy was significantly higher among patients with high versus moderate disease activity (57% vs 48%, respectively). In addition, the importance placed on patient preference significantly decreased among those with high versus moderate disease activity (11% vs 15%, respectively).

“Independent of the patient’s disease severity, expected drug efficacy clearly dominated treatment choices when rheumatologists were faced with a treatment adjustment. However, for patients with moderate disease activity, efficacy became somewhat less important, when compared with drug choices for patients with high disease activity. This probably emphasizes the urgency recognised by rheumatologists in efficaciously suppressing inflammation, particularly in the presence of high disease activity,” the researchers said.

Unloading Knee Brace Cost-Effective for Bridging Therapy, Delaying Surgery

Use of an unloading knee brace in patients with unicompartmental osteoarthritis (UOA) is cost-effective and can reduce both the frequency of surgery and the severity of surgical intervention, according to the results of a recent study (Lee PY, et al. BMJ Open Sport Exerc Med. 2017;2:e000195).

Because unloading knee braces have been shown to provide good short-term pain relief for patients with UOA, and because of a lack of data on their use for ≥5 years, the researchers sought to assess the cost-effectiveness of the brace. To do this, they analyzed 8 years of follow-up data for 63 patients with UOA of the knee who attended a general hospital between August 2007 and February 2009, and who were prescribed the brace while on a waiting list with a duration of 8 months for total knee replacement (TKR) surgery.

Responses to EuroQol 5 Dimensions (EQ-5D) questionnaires were collected at baseline and after the patient had ceased wearing the brace or at the end of the study period in 2015. The researchers then compared the cost and quality-adjusted life-years (QALYs) of the unloading knee brace with those of TKR, accounting for 8 years of results.

Patients who wore the brace for an average of 26.1 months had a mean increase in EQ-5D of 0.42, which resulted in a QALY increase of 0.44 with a mean cost of £625. A progressive, 8-month cost-effectiveness ratio of £9599 was also observed with the adoption of an unloader knee brace. At 8 years, and compared with TKR, the brace demonstrated a QALY gain of 0.43, and a progressive cost-effectiveness ratio of -£6467.

These results led the researchers to assert that, compared with having no treatment, the use of a knee brace is cost-effective at ≥4 months.

“The unloader knee brace can delay surgery and indeed deem it unnecessary over the long term for patients (39%) with unicompartmental arthritis. Patients were able to return to their daily activities and work while using the unloader knee brace,” they concluded.

Type 2 Diabetes a Significant Short-Term Risk for Patients with Rheumatoid Arthritis

The short-term risk for type 2 diabetes is significant among patients with rheumatoid arthritis (RA), according to the results of a recent study that also demonstrated the close relationship between uncontrolled disease activity and glucose metabolism derangement (Ruscitti P, et al. PLoS One. 2017;12:e0181203).

Because cardiometabolic comorbidities (eg, type 2 diabetes) remain underdiagnosed and undertreated in patients with RA, researchers sought to examine the incidence of type 2 diabetes in this patient population during the course of a 1-year follow-up. They also investigated the role of traditional cardiovascular and RA-specific risk factors in predicting type 2 diabetes occurrence.

In their 12-month, single-center, prospective study, the researchers examined 439 patients with RA and no previous diagnosis of type 2 diabetes and followed up with them every 3 months. Disease activity was assessed using the Disease Activity Score-28 (DAS28); sequential DAS28 scores were used to evaluate treatment efficacy in accordance with European League Against Rheumatism (EULAR) response criteria.

After 12 months of follow-up, 31 (7.1%) patients had type 2 diabetes, and 34 (7.7%) had an impaired fasting glucose. According to a regression analysis, high blood pressure, impaired fasting glucose, and a poor EULAR-DAS28 response were strong predictors of an increased risk for type 2 diabetes. Similarly, high blood pressure and a poor EULAR-DAS28 response were linked to an increased probability of having an impaired fasting glucose.

Based on these results, the researchers concluded that there is a significant short-term risk for type 2 diabetes among patients with RA, and that there is a strong association between uncontrolled disease activity and imbalanced glucose metabolism.

“A better management of persistent poorly controlled RA patients, with conventional therapies and biologic drugs, could confer additional benefits on the joint damage as well as on cardiometabolic comorbidity, thus improving long-term outcome,” they said.

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Last modified: January 15, 2018
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