Article Text
Abstract
Objective: To study the influence of rheumatologists’ adherence to a methotrexate guideline on efficacy and toxicity in the treatment of rheumatoid arthritis.
Methods: In a 48 week randomised controlled trial of methotrexate, comparing folates with placebo, rheumatologists were advised on methotrexate dosage using a guideline reflecting daily practice. The influence of guideline non-adherence on outcome was analysed using generalised estimating equations and survival analysis.
Results: In 51% of the 411 study patients the guidelines were always followed. Non-adherence resulted in lower doses of methotrexate in 25% of cases, and higher doses in 24%. The reduction in the disease activity score was significantly greater (mean −0.4; p = 0.0085) in the adherent group than in the “low dose” group; the “high dose” group did not differ from the adherent group. Dropout caused by severe adverse events did not differ between the three groups.
Conclusions: There is an indication that adherence to guidelines on methotrexate dosage may benefit patients with rheumatoid arthritis by improving disease activity without increasing toxicity. For definite proof, a randomised controlled trial comparing guideline supported dosing with usual care is needed.
- ACR, American College of Rheumatology
- DAS, disease activity score
- DMARD, disease modifying antirheumatic drug
- EULAR, European League Against Rheumatism
- RAI, Ritchie articular index
- RCT, randomised controlled trial
- TNFα, tumour necrosis factor α
- VAS, visual analogue scale
- rheumatoid arthritis
- methotrexate
- outcome