Anti-rheumatic drug-prescribing behaviour of Australasian rheumatologists 1984-1994

Treatment of pregnant and non-pregnant rheumatic patients: a survey among Dutch rheumatologists

BACKGROUND

The aim of this study was to explore, among Dutch rheumatologists, aspects such as attitude towards guidelines, pharmacotherapy and information needs in the treatment of pregnant as well as non-pregnant rheumatoid arthritis (RA) patients.

METHODS

Fifteen rheumatologists from nine different hospitals were interviewed by means of a semi-structured interview. Questions addressing attitude towards guidelines, pharmacotherapy preferences and information needs with respect to the pregnant and non-pregnant patient were asked. The analysis will be based on descriptive statistics.

RESULTS

Guidelines are used by almost half of the hospitals with respect to pregnant RA patients and by all hospitals for RA patients in general. With respect to pregnant women, nine respondents preferred stopping the medication as soon pregnancy is known. When treating RA patients, in general sulfasalazine and methotrexate would be drugs of first choice. Information is found in international and national books and guidelines.

CONCLUSION

Dutch rheumatologists are of the view that there is sufficient information on the treatment of RA in pregnant women or women wishing to become pregnant, except for safe use of medication during pregnancy. In the future, pregnancy risk categorization should be updated and discussed regularly. This should be based on more recent literature and experience. A good monitoring system for following all young patients with a rheumatic disease should be set up as a first step to collect more information on the safe use of medication during pregnancy.

Prescription rheumatology practices among Mexican specialists

BACKGROUND

We undertook this study to describe prescription practices and the degree of disease control in a large sample of patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) treated by rheumatologists in Mexico.

METHODS

Board-certified Mexican rheumatologists across the country were asked to assess consecutive RA and AS patients; 1208 patients completed a self-administered questionnaire with information on demographics, disease duration, co-morbidity, treatment, pain, disability and a validated Spanish version of instruments to measure physical function and quality of life.

RESULTS

Of the 1096 RA patients, 88.1% were treated with nonsteroidal anti-inflammatory drugs (NSAIDs), 1020 (93.3%) with disease-modifying anti-rheumatic drugs (DMARDs), 365 (33.4%) with steroids, and 70 (6.4%) with biological agents. Their mean Health Assessment Questionnaire Disability Index (HAQ-Di) score was 1.21+/-0.80, Disease Activity Index, 28 joint count (DAS 28) 3.9+/-1.29, and Rheumatoid Arthritis Disease Activity Index (RADAI), 3.94+/-2.01. Regarding the 112 AS patients, 110 (98.2%) received NSAIDs, 90 (80.4%) were on DMARDs, 11 (9.8%) took steroids, and 11 (9.8%) received biological agents, their functional status shown as Bath Ankylosing Spondylitis Functional Index (BASFI) score of 4.4+/-2.5. Among the 1110 DMARD users, only 64 received one drug, and a great proportion used two or more DMARDs; 81 subjects (16.2%) were on biological agents, in any combination. RA patients more commonly used methotrexate, 791 (72%) cases, and hydroxychloroquine. Taking into account their diagnosis, the combination most prescribed was NSAIDs plus DMARDs in 660 subjects (54.7%).

CONCLUSIONS

DMARDs in combination with other drug are the most frequently prescribed therapeutic scheme for RA and AS patients. These schemes used for both conditions by Mexican rheumatologists are in line with current international recommendations.

How is leflunomide prescribed and used in Australia? Analysis of prescribing and adverse effect reporting

PURPOSE

To evaluate the use of leflunomide in the Australian community since introduction in 2000. Trends in adverse drug reaction (ADR) reporting were also studied.

METHODS

Annual Australian prescription and dispensing statistics were analysed. Drug utilisation was estimated as defined daily doses (DDD)/1000 inhabitants/day. ADR data from the Therapeutic Goods Administration's Adverse Drug Reactions Advisory Committee (ADRAC) national monitoring system were compared with the World Health Organisation (WHO) Vigibase records.

RESULTS

Leflunomide use in Australia (dispensing data) increased from 0.2 in 2000 to 0.4 DDD/1000 inhabitants/day in 2002. The same overall pattern was observed in the 'authority to prescribe' data. From 2000-2002, prescribing of the starter pack (3 x 100 mg loading dose plus 30 x 20 mg tablets) declined (down 74%); likewise for the 20 mg (30 tablets) pack. Gradual increases were noted for the 10 mg (30 tablets) pack (up 40%). Approximately 135 reports, detailing about 370 individual ADR, were generated annually. Gastro-intestinal disorders predominated, accounting for 24% of reactions reported to ADRAC. Skin and appendages disorders constituted 14% of reported reactions. Deaths in leflunomide users were attributed to a combination of haematological and gastro-intestinal complications, but it was not possible to ascertain other medication usage or contributing factors. Trends observed with the ADRAC reports were consistent with the WHO database.

CONCLUSIONS

Leflunomide was the first registered DMARD in Australia in over a decade and its use has increased within the community. The ADR reports might have contributed to Australian rheumatologists gradually abandoning loading patients with high doses of leflunomide in favour of starting therapy at lower doses.

Changes in use of disease-modifying anti-rheumatic drugs in Australia over the period 1992–2004

PURPOSE

Evidence is growing that early use of disease-modifying anti-rheumatic drugs (DMARDs) and combinations of these drugs provide optimal care for people with rheumatoid arthirits. The aim of this study was to describe objectively the pattern of consumption of DMARDs in the Australian community (community-based prescribing, specialist and general practitioner) 1992-2004, and to compare this with prescribing patterns reported in other countries.

METHOD

Dispensing statistics from the Pharmaceutical Benefit Scheme (PBS-Australia's universal prescription subsidy scheme) were analysed and temporal trends evaluated. Drug consumption was calculated as the number of dispensed defined daily doses (DDD)/1000 inhabitants/day (WHO ATC/DDD classification 2005).

RESULTS

The consumption of DMARDs in the Australian community increased steadily from 2.6 DDD/1000 inhabitants/day in 1992 to 5.5 DDD/1000 inhabitants/day. Over the period 1992-2004, methotrexate (MTX) was the most commonly used DMARD (from 0.6 to 3.0 DDD/1000 inhabitants/day). Consumption of gold (parenteral and oral) and penicillamine declined during this time. The inclusion of leflunomide on the PBS in 2000 contributed to the increase in DMARD usage.

CONCLUSION

Use of DMARDs within the Australian community has increased in recent years, coinciding with the change in guidelines for therapy for rheumatoid arthritis (RA) to earlier use of DMARDs and the more common use of combinations. This study used DDD methodology to quantify trends for DMARD consumption and these trends are broadly consistent with international prescribing patterns assessed using different methodologies.

The national database of the German Collaborative Arthritis Centres: II. Treatment of patients with rheumatoid arthritis

OBJECTIVE

To describe current treatment of patients with rheumatoid arthritis (RA) in German rheumatology.

METHODS

Data from the German rheumatological database of 1998, comprising clinical and patient questionnaire data of 12 992 outpatients with RA seen at 24 collaborative arthritis centres in Germany, were analysed.

RESULTS

At the time of documentation, 88% of the patients with RA were undergoing disease modifying antirheumatic drug (DMARD) treatment. Methotrexate (MTX) was prescribed to 56% of the patients (61% with seropositive and 45% with seronegative RA). Combination treatment was used in 15%. MTX was the drug of first choice even in patients with up to one year's disease duration (49%), followed by antimalarial drugs (21%). Patients treated by non-rheumatologists within the previous year had received DMARD treatment in only 33% of the cases. In steroid treatment, low doses (< or = 7.5 mg/day) were used by rheumatologists much more often (44%) than higher doses (12%). 16% of the patients had been inpatients during the previous year, with a median length of stay accumulated over the year of 21 days. Together with stays in inpatient rehabilitation, 22% of all patients had had some form of inpatient treatment. Comprehensive measures such as occupational therapy and patient education were prescribed to fewer than 12% of the patients, mostly during their hospital stay.

CONCLUSION

German rheumatologists do follow recent recommendations about early and effective treatment. However, there are still deficits in outpatient care with non-medicinal measures like occupational therapy and patient education, which may partly explain the high hospital admission rates.

Established rheumatoid arthritis

Currently the diagnosis of rheumatoid arthritis (RA) may be difficult; the ACR criteria appear most sensitive and specific in long-standing disease. Without clear definition or diagnostic criteria for early disease it is difficult to define late or established RA. The distinction between early and established RA has been further blurred by recent imaging studies that suggest even in what is currently termed early disease, there is evidence of joint damage. The natural history of RA suggests that most patients with clinic-diagnosed RA have a progressively disabling course, but evidence is growing that modern therapeutic strategies result in better long-term outcomes, especially when applied early in the disease course. In established disease, quantitative markers such as C-reactive protein (CRP) give prognostic information, but in the pre-erosive, early phase of the disease the qualitative markers such as rheumatoid factor (RF) and shared epitope are crucial. As rheumatologists, our major aims must remain: (1) to diagnose the disease as early as possible; (2) to identify those patients with poor prognosis who will benefit most from targeted therapy; and (3) to aim for more intensive disease control irrespective of disease duration.

Health services research

In the past year, several publications have reported on aspects of health services research in regard to musculoskeletal disorders. Utilization studies in the elderly have shown that an effective procedure such as hip arthroplasty may be underused in this population. As well, surgical complications in these patients appear to vary according to the number of procedures performed in a hospital, with high-volume hospitals showing better outcomes. Studies of practice patterns show variations among rheumatologists in the treatment of various rheumatic diseases. Practice variations between physician groups, in particular, rheumatologists versus primary care providers, have also been reported. Several studies show that primary care physicians may have some difficulties in diagnosing common rheumatic disorders. There is some evidence as well that rheumatologists may provide better care for some conditions, such as rheumatoid arthritis. These findings have major implications for restrictions to patient access to specialist care by health organizations. A variety of clinical practice guidelines have been developed and tested, most aimed at general practitioners. Physician compliance with guidelines continues to be low for most implementation strategies. Multidisciplinary programs for the treatment of rheumatoid arthritis appear to have a somewhat beneficial effect. Programs based only on patient education appear to have short-term gains, and longer-term effects are diluted because of noncompliant behaviors.